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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ICIPERATOR <br /> /1/ CHECK If BILLING ADDRESS <br /> FACILII't NAME y(/ pry �r(�',�l�J <br /> SITE ADDRES '/Q rv,I A� .L/FJ� Er N ;' / J•J 'I <br /> /T Sireet Number Direction Street Name CI Zi Cotle <br /> HOME Or MAI <br /> 3LING ADDRESS J/ /(If Di%rent from Site Address) <br /> q ' �' <br /> N S� Street Number Street Name <br /> CITY 4'r <br /> A/ STATE ZIP <br /> a'V <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORI T +UU CHECK If BILLING ADDRESS <br /> BUSINESS NAME L PHONE# EXT. <br /> ' S <br /> HoM�Or MAILING ADDR SSS FAX# <br /> `$ <br /> 9/ 51-' ( ) <br /> CIN S OC Toti/ STATE C_/ /J 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 billyd 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,S a/JE ' dd FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: �/�EEG� DATE: 2—3/ — /✓ <br /> PROPERTY I BUSINESS OWNER VJ 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 same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Try 0 le)N%: J VY� <br /> COMMENTS: PAYMENT <br /> RECEIVED I <br /> DEC 31 2015 <br /> SAN JOAQUIN COUNTY <br /> £NVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: HEAT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alreAlly completed): SERVICE CODE: <br /> PIE: 3 <br /> Fee Amount: _ Amount Paid (J3� d C__) Payment Date <br /> k Invoice# Check# a O Received By <br /> Payment Type G : <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />