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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> -Mc i s� 00��532- <br /> OWNER/OPERAT R <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME u ! – <br /> 76 Q O�� ��/ <br /> `SITE 7ADDRESr-S\\ 1�+ /JJ� <br /> V Street Number Direction —"�� 14tr! tT�me ���. CI ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �G oorl STATE ZIP Cy <br /> - r q), 3 a 9 a ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REOUESTOR <br /> REQUESTOR <br /> �A A CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 ( PHONE# ExT <br /> C'Ct (AISQ # 77OSa zcfl (p 3 <br /> HOME or MAILING ADDRESS , FAX# <br /> CITY STATE Cc, ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> acknowledge that all Site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated With this project Or , <br /> activity will be billed to me or my business as identified on this form. - <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: &,I - 104,1,42 7,Gc DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY Proof Of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the sP�fjfQWauvided to me or <br /> my representative. AHir NI <br /> TYPE OF SERVICE REQUESTED: ' (/1'L RECEIVED <br /> COMMENTS: o,F -ro to n 1 MAY 2 2 2017 <br /> -JItJ Q So�G`� `JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> L f CJ HEALTH DEPARTMENT <br /> ACCEPTED BY: �• EMPLOYEE#: DATE: 5 Z� ' <br /> ASSIGNEDTO: GIJ EMPLOYEE#: DATE: �� 1-7 <br /> Date Service Completed (if already completed): $ERVICECoO NI PIE: �o <br /> Fee Amountrj r V Amount Paid (3 0( • Payment Date v �- .�';k, I -� <br /> Payment Type C cA S Invoice# Check# — Received By: <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />