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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Q (E� a-7 Lo <br /> OWNER/OPERATOR <br /> r1 �\ CHECK If BILLING ADDRESS <br /> \AC7 <br /> FACILITY NAME <br /> SITE ADDRESS S. GYUvtnCv\E'O fit"". LO CL\ Cts 24C� <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Sit\e Address) >rO..YLC QG-Y\L— l�V <br /> k IJ� Street Number Street Name <br /> CITY STATE ZIP <br /> (naa\- LC' qS(n 2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOB DISTRICT L I CT LOCATION CODE <br /> I ) as <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME " PHONE# EXT. <br /> S Zo`l 1LiL�-O�a O <br /> HOME or MAILING ADDRESS FAX# <br /> \003 \Lc G L k ASO ( ) <br /> CITY --k— STATE ZIP n <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,STATE and FEDERAL laws. <br /> APPLICANT'S <br /> C� <br /> APPLICANT'S SIGNATURE: _= ��` x DATE: <br /> PROPERTY I BUSINESS OWNER O! OPERATOR I MANAGER Etr OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 /> t0 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. WMENT <br /> TYPE OF SERVICE REQUESTED: CJ <br /> COMMENTS: <br /> LIG JUN 15 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: rp EMPLOYEE M DATE: 7r <br /> ASSIGNED TO: h m/C EMPLOYEE DATE: <br /> Date Service Completed (if al eady completed): SERVICE CODE: i PIE: <br /> Fee Amount: I��' �� Amount Paid \!59 9 0 Payment Date <br /> Payment TypeAme.)c Invoice# Check# Received Bye <br /> END 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />