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SAN JOAQU,. COUNTY ENVIRONMENTAL HEALTH G,-r'ARTMENT <br /> SERVICE REQUEST <br /> Tyy�of Business or roperty FACILITY ID# SERVICE REQUEST# <br /> iiG ^ iM 4 © Sr�OU�S(1-1 3 <br /> OWNER I OP AT R <br /> -- / CHECK If BILLING ADDRESSL� <br /> FACILITY NAME <br /> ///���� Mann 's Dq <br /> SITE ADD ESS <br /> Street Number Direction a Ct Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ' <br /> C— Street Number L V/reet Name <br /> CITY /- S TE T'5 2�i <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PNE#2 BOS DISTRICT LOCATION CODE <br /> ) 0 �a <br /> CON'TRAC'TOR SERVICE REQUESTOR <br /> REQUESTORp �� CHECK if BILLING ADDRESS <br /> l It <br /> BUSINESS NAME 6 I PFfQN # ^ j ` EXT. <br /> HOME Or MAILING D SQ/ FAX# <br /> / <br /> CITY STA ZIP S <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,STAT and FEDERAL �. <br /> APPLICANT'S SIGNATURE: _ <br /> / DATE: <br /> PROPERTY/BUSINESS OWNER CJ 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: flIba V I dL U <br /> COMMENTS: <br /> I~ S tit w s va r( I 6 ire- f-(d In va II e j o. <br /> �uN � 3 2016 <br /> P,t4 JC)AOOMt TA1- <br /> �uo EN <br /> ACCEPTED BY: )kY �l l/ ( /1 EMPLOYEE#: DA [,E1A}M?f I <br /> ASSIGNED T0: � IA�U 1 1 G n V EMPLOYEE#: DATE: VO�r� <br /> Date Service Completed (if already Completed: SERVICE CODE: Se v I n ' PIE:' <br /> 7 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />