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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�;it� ��Y+!�i��`,e ���<<1,� y i`t�J'•'�' CHECK if BILLING ADDRESS <br />BUSINESS NAMES <br />!.M <br />FACILITY ID # <br />P(yI0( EXT. <br />SERVICE REQUEST # <br />l �1 <br />FAX # <br />( ) <br />CITY <br />ASSIGNED TO: <br />STATE <br />% ZIP q <br />EMPLOYEE #: <br />OWNER / OPERATQR' <br />Date Service Complated (if already completed): <br />SERVICE CODE: <br />Fee Amount: tk <br />V�4 <br />Amount Paid <br />CHECK if BILLING ADDRESS �..! <br />FACILITY NAME <br />Payment Type G�� <br />Invoice # <br />Check # at f C� <br />SITE ADDREn .^ <br />1 <br />l/%.� <br />treat trumber <br />Direction <br />r )``9/1 -e <br />Name ` `" <br />C <br />Zip de <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street <br />Number <br />Street Name <br />CITY <br />STATE ZIP Y� <br />LA <br />p�ov #1 t EXT. <br />APN # <br />LAND, U$ , APPLICATION # <br />P 0 E #2 EXT. <br />OS DISTRICT <br />LOCATION CODE <br />CONTM, C E Vjji I fit,QUESTOR <br />REQUESTOR <br />�;it� ��Y+!�i��`,e ���<<1,� y i`t�J'•'�' CHECK if BILLING ADDRESS <br />BUSINESS NAMES <br />!.M <br />((�T��l p/1 J t 1 <br />✓f �.-'1:� •"I .tel /, ,,- <br />P(yI0( EXT. <br />HOM O MAILING ADD ESS <br />C� I� L�n✓1 <br />sl <br />l �1 <br />FAX # <br />( ) <br />CITY <br />ASSIGNED TO: <br />STATE <br />% ZIP q <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, Sta ards, and F RAL laws. <br />APPLICANT'S SIGNATUR DATE. `l �� /,-, <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR / MA GER 13 OTHER AUTHORIZED AGENT ElY <br />It APPLICANT Is not the BILLING PARTY, oof 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 met , <br />my representative. <br />TYPE OF SERVICE <br />' <br />REQUESTED: <br />COMMENTS: j/r/m-P"r <br />C-�ISI-Acs <br />( 3 I -.PF -#n) <br />� �A � � 1) .2 %%/jQ�/f /I <br />C&.4 wL1 WJ ��, �f� -a !E' I' ' /�'/'A(. -rD <br />-415f;-16 C- I- r&M r &A/ 6(7-71-,"v6, t�eAoo M <br />WA -3 Pcwwrd) . 6th Com) 9s3 - 76q 7 /*Iz 1/f -S - <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Complated (if already completed): <br />SERVICE CODE: <br />Fee Amount: tk <br />V�4 <br />Amount Paid <br />l 3 c9, 0 � <br />Payment Date <br />Payment Type G�� <br />Invoice # <br />Check # at f C� <br />Received Bye <br />M <br />EHD 48-02-025 SR FORM (Golden Rod) <br />0717/08 MAY 0 4 2016 <br />SAN JOAQUIN COUNTY <br />ENVIROMENI-AL <br />HEALTH DEPARTMENT <br />M <br />