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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i` g4Z U07`I'SOcI <br /> r <br /> OWNER/OPERATOR <br /> , `C�, c�s� CHECK If BILLING ADDRESS <br /> Yw <br /> FACILITY <br /> INAME <br /> SITEADDRESS <br /> StreetNumber I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> �' { e W� Street Number Street Name <br /> CITY - STATE ZIP <br /> � i l '� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> VC- I Z_2 fy 7*7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 0 r CHECK If BILLING ADDRESS® <br /> BUSINESS NAME"" PHONE# ) <br /> ExT. <br /> Qj,S f(!al YV� <br /> HOME or MAILING ADDRESS FAX# I <br /> / S zor ✓i &—L./ L I ( ) <br /> CITY re,-f a <br /> /FS 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, SAE and FEDERAL laws. t <br /> APPLICANT'S SIGNATURE: Fk �/�� DATE: U3 )3,1 <br /> PROPERTY I BUSINESS OWNER❑ OPE, TOR/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. ^^ IPQ �r <br /> TYPE OF SERVICE REQUESTED`: (�(� Cori � Y <br /> COMMENTS: «� [/. �+ ;' MAR 31 2016 <br /> / SAN JOACUIAl CO <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 5 . 3/-46. 3/_/ <br /> ASSIGNED TO: I —Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): -- SERVICE CODE: /C *Recelved <br /> J�Q'7 <br /> Fee Amount: I Amount Par" /3n O Payment DatPayment Type ! Invoice# Check# , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> \ 07!17/08 <br />