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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L.cPARTMENT <br /> SERVICE REQUEST <br /> r Type of Business or Property- ,Oo2o3os FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING AOORESSE] <br /> FACILITY NAME 4:-9InJ�` <br /> TE ADDRESS'[\t �23 _ <br /> L/ Street Number JDirn 1 ee Name t ZI Cake/ <br /> E Or MAI G AyDo��DRESS (If Brent from Site Address) <br /> O6) ' (� Street Number Street Name <br /> CITY `v JI�+v-h /�CE q4 � q <br /> P NEEXTAPNLAND USE APPLICATION# <br /> P ONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORer <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ( n /'� C PHO # EXT. <br /> l�(—eo 5 q 3 3 8 s c� <br /> HOME or MAILING AD O / (AX# ) <br /> CITY M- C I J l J STAT � 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 /> 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. G 1 <br /> APPLICANT'S SIGNATURE: ,4�000s�— DATE: I I l 1 <br /> ROPERTY/BUSINESS OWNIEfE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY proof Of authorization f0 sign is required Title <br /> AU ORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 Same time It is provided to me Or <br /> my representative. \ / <br /> RAMMONT <br /> TYPE OF SERVICE REQUESTED: U yQ�(N'�j �Q <br /> COMMENTS: <br /> N6W 0 JAN r y 2017 <br /> SEIjOAQUIN COUNTY <br /> VIRON AL <br /> 1/ HEALTH DEPARTMENT <br /> ACCEPTEDBY: wkb,� EMPLOYEEM DATE: ` lqll� <br /> ASSIGNED TO: �t N �,I , EMPLOYEE#: DATE: I I I <br /> Date Service Completed (if already completed): SERVICE CODE: 6 P/E: U 3 <br /> Fee Amount: ` 3 a) I Amount Paid 13 `1 V Payment Date 1 19 1-7 <br /> Payment Type C4 Invoice# Check# Received By: <br /> U <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />