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SAN JOAQUIN #UNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 \-A&\AA IU-s S 'Roo L- 1406n;> S-71 vR bG-7/DM <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAM ` R r T <br /> SITE ADDRESS cis S <br /> y Street Number Direction Name t Ci R 2i Cotle Y <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY ` STATE ZIP <br /> PHONE#1 J En. APN# LAND USE APPLICATION# <br /> (_7_7 1; 338— S \9 2 - 233��s3t$ <br /> PHONE#2 En. II \1 SOS DISTRICT LOCATION CODE <br /> A - S3 - 2aq - VAA11 ,t-Q- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADORES <br /> BUSINESS NAME(` " J P NE# ExT' <br /> ^M o C-15'- 125 <br /> HOME or MAILING ADDRESSFAX <br /> l <br /> CITY \ STATE e p zip q q S' Ca G <br /> BILLING ACKNOWLEDGEMENT I, a undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or proje spe ific ENvIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my b Sine s as identified on this form. <br /> I also certify that I have prepared s li tion and tha he work t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand rds S and F DEKA laws. -'T r ' <br /> APPLICANT'S SIGNATURE: �.( tqf DATE: 1 `�� �7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHERAUTHORIZED AGENT COU \J2hC\O •C <br /> V'APPLICAVT is not the BILLING PARTr proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAMEW <br /> TYPE OF SERVICE REQUESTED: 'i" RECEIVED <br /> COMMENTS: NOV 2 3 2016 <br /> 6 w t wwt t 1,.3 S ` o !3 . � ec <br /> SAN <br /> Y C71 C� 1 w� a0,{ HEALTHROMENTAL <br /> UIN COUNTY <br /> DEIWYMMT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ZC7 EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 5�3 PIE: <br /> Fee Amount: �— I Amount Paid �, 7 8 • C" 0 Payment Date I <br /> Payment Type C (< Invoice# Check# Received By:Z <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />