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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gfZ Q67 e <br /> OWNER I OPERATOR <br /> A m �S� CHECKIf BILLING ADDRESS❑ <br /> FACILITY NAME CI�.O�J'J�t IC:LO�tJ <br /> SITE ADDRESS T <br /> eon wes'l T)?J Et -r' c,- (% vtfa•✓ � SaBy <br /> Street Number DlrectIm Street Name CI ZLCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street I:amber L _ Street Name <br /> CITY (o /' STATE ZIP <br /> PHONE#t '>T5CL<tV01J C R E-'qC 209 APN# LAND USE APPLICATION# <br /> (Z ) qSl 43 <br /> PHONE#I IT. 130S DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR . Cp— Cy'�t)(V 1 Y <br /> \\ CHECK If BILLING ADDRESS <br /> BUSINESS NAME P QNE# En. <br /> t,,, <br /> HOME or MAILING ADDRESS FAX# <br /> '790 t-.f4V0; ( ) <br /> CITY 1'12 ^ STATE // ZIP(,7 <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 FEDE`L I�wS. <br /> APPLICANT'S SIGNATURE:r �jf l ��� DATE: Z///c <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR i MANAGER OTHER AUTHORIZED AGENT Clr}/t I( )j— <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 Sign is required. Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 me or <br /> my representative. /� <br /> TYPE OF SERVICE REQUESTED: �,e�J rO�' Q r(� lam PAYMENT <br /> COMMENTS: rltGEIVED <br /> FEB 19 2016 <br /> SAN JOAQUIN COUNT <br /> HEENVIROMENTAL <br /> ALTH OEPq iTM[ <br /> M. <br /> ACCEPTED BY: LAPLOYEE DATE: <br /> ASSIGNED TO: cnz-n EMPLOYEE M DATE: a 13 <br /> Date Service Completed (If already completed): SERVICE CODE: rte- OP�!E: <br /> Fee Amount: ount ct'6- ,b(7 Payment Date Z lei I(p <br /> Payment Type Invoice# Check# `l g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />