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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LJEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .00 73 s10,o0-7LJ32sz <br /> OWNE OPERATOR H n p K.9 AT S. 6 HIUMAN ❑ <br /> r 1 1� I CHECK If BILLING ADDRESS <br /> FACILITY NAME G I i )t MA�-1 <br /> 'IL CC�RE� :A� -7�DU20 1 <br /> SITE ADDRESS <br /> LOCO IJ `I S�(QS <br /> J Street Number I Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) yp,� <br /> G s '\ --��" Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Abcu �5-Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Gti0MA14 ICE CRC QM PHONE# �oq—qq—)03 EXT. <br /> HOME or MAILING ADDRESS 16 /0L ftN'TAU1304 AUF- FAX# <br /> I V ( ) <br /> CITY S70 <br /> C `f STATE C A ZIP S�f <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 applic2`ion and that the work to be performed will be done in accordance with all SAN JOAOUIN <br /> COLIN Y Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: km, J&44J- DATE: <br /> PROPERTY/BUSINESS OWNER 1�r OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY /hoof of authorization to sigh 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is provided t0 me Or <br /> my representative. l ' .� - <br /> TYPE OF SERVICE REQUESTED: yQ C/I Pi .1/�ls �� PAYMENT <br /> COMMENTS: RECEIVED <br /> Nl. 0 3 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L EMPLOYEE#: DATE: <br /> Date Service Completed (if already comp—ted): SERVICE CODE: SLp� f P I E: I(pts <br /> Fee Amount: C$�bO* Amount Paid 3 V �, Payment Date o3 A <br /> Payment Type L�5� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />