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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ter-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IQ,# SERVICE REQUEST# <br /> Ion '�)V-06-7 �) ]�> <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> r <br /> FACILITY NAME <br /> SITE ADDRESS III /' A„ v TC1'�)2—4-1) <br /> Street Number Direction Street Name c1tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) + j i C �U r,C) S� <br /> Street Number ^ Street Name <br /> CITY W 6b STATEht' 4--1 �4 V <br /> Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> YI 5��1^ �� "�XC cy,, CHECK If BILLING ADDRESS <br /> BUSINESS NAME-^7V* , a� n�1 PHONE# � ) - Exr./ <br /> HOME or MAILING}ADDRESS C�X FAX# lU <br /> CITY STATE //t ZIP �'5z <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> t activity will be billed to me or my business as identified on this form. <br /> 1 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: 425�2� DATE: 7 , <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NVINAGER� 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: i <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> OEC "2 8 2016 <br /> 1 SAN JOAQUIN COUNn <br /> ACCEPTED BY:'Qc EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: _ Amount Paid 1'� ." Payment Date I <br /> Payment Type C`e Invoice# Check# ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />