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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s(oomqK <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS I- I C SAIL <br /> 3 Street Number Direction , r t Namd '� r CI T JZI Cotllo <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> C <br /> t <br /> bh 14 8521 <br /> n 5 el umber Stre¢t Name <br /> CITY STATE zip <br /> (BONE 7 E%r. qPN# LAND USE APPLICATION# <br /> Rqcq <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING AOD SS <br /> BUSINESS NAMEPHONE <br /> aqf; in1 # / <br /> L _L <br /> HOME or MAILING ADDRESS FAx# <br /> It IAQ afi ) a5J- 7c,.-2 <br /> CITY STATE ZIP \ / <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 /> I 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. J 2 <br /> APPLICANT'S SIGNATURE: DATE: LJ- 3U-1'7 <br /> PROPERTY/BUSINESS OWNER 1:1 OP RAP R/MANAGER ❑ OTHERAUTHORIZEDAGENTJlr Q!SL01.r <br /> If APPLICANT IS not the BILLING PARTY,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 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 tlmp,jt is provided to me or <br /> my representative. 4 <br /> TYPE OF SERVICE REQUESTED: 7JWn-- CEIWo <br /> COMMENTS: <br /> Cl ec-Frow(� 1'(OIriS SAN JOy R 3 2019 <br /> ENORONM COUNTY <br /> HEALTH DEPARWrAL <br /> ACCEPTED BY: EMPLOYEE III: DATE: 4130110 <br /> ASSIGNED TO: cw EMPLOYEE#: DATE: <br /> Woo <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: (id <br /> Fee Amount: - Amount Paid [.f s� �D Paymi Date 1 ado 1 I q <br /> Payment Type ✓ Invoice# Check# Received By: t6 , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> `l-I "L <br />