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SAN JOA(Qv..4 COUNTY ENVIRONMENTAL HEALTH L EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Flo i ^D o c� r-T ;9, C)ON 13 <br /> OWNER/OPERATOR <br /> J C) Ql <br /> CHECK If BILLING ADDRESS <br /> r <br /> FACILITY NAME I �� ^ <br /> SITE ADDRESS -7 3 v } <br /> _ C' ��� uv ✓�i S� xK��n ojS�v3 <br /> Street Number Direction Street Name c1tvZi Code <br /> How Or MAILING ADDRESS (If Different froT Site Address) l I I^ v <br /> fI Street Number Q� to-'— Street Name <br /> CITY J(�C< o n STATE �� LIP <br /> PHONE#1 lEXT. APN# LAND USE APPLICATION# v/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUES•TOP t <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME i� � \ n�� _ 1 J PHONE# — �EXT. <br /> HOME or MAILING ADDRESS W (, (/\ FAX# <br /> CITY ; STATE 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, .TE and FEDER laws <br /> APPLICANT'S SIGNATURE: XA� _ DATE: <br /> PROPERTY/BUSINESS OWNER❑ 7OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> A'v'T HORIZATiO1'i TO RELEASE iNFORiriATION: When applicable, i, the ownet ur 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 t0 me Or <br /> my representative. r <br /> TYPE OF SERVICE REQUESTED: VeAkA c_i e_ T4, EN 1 <br /> COMMENTS: <br /> FEB 0 5 2016 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: r/ C (��i/ w�,t �MPLOYEE#: DATE: f Sp <br /> Date Service Completed (if already completed): SERVICE CODE: � PIE: ((P� <br /> Fee Amount: 41-- Amount Amount Paid l`3 o, d C Payment Date <br /> Payment Type Invoice# ChtCk y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />