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SAN JOAQ• COUNTY ENVIRONMENTAL HEALTH*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> O A) /T <br /> /Y �LI ni CHECK if BILLING ADDRESS <br /> FACILITY NAME .rplulF �("_'C�{ /'i/►'(✓� s <br /> SITE ADDRESS 15130 <br /> C1 "?p �Q�� ������ �� ��,_11_ �O� 9's3 3 <br /> 0 <br /> street Number Direction Street Name `F�'l CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '/ ^ w <br /> �6 A)6- �7'�/V' CHECK If BILLING ADDRESS <br /> BUSINESS NAME , PHONE# E.T. <br /> T R u Tou c(f ILi,4l LS SIM 'to gS' - S8'�7� <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP CjS,-,2iJ. <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 /> 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 SIGNATURE: ,o/ _ DATE: <br /> PROPERTY/BUSINESS OWNER 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 /> 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. <br /> TYPE OF SERVICE REQUESTED; 42 1 Q ' ' °�" <br /> HE <br /> COMMENTS: <br /> P(avt CLI ect NOV 0 7 2016 <br /> SAN JOAQUIN COUNTh <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ f <br /> ASSIGNED TO: tA • C , EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 , P/E: <br /> Fee Amount: ,N Amount Paid Payment Date ( - 7— / 6 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ( `M (.P S5 4x> SR FORM(Golden Rod) <br /> 07/17/08 <br />