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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C.eC 6 e� X31 3 T�5 7grj j <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> IF <br /> SITE ADDRESS ^'y�` <br /> Stre�l�umber Direction � �� Name - -' x/L CI Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E.T, APN# I wv LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CO E <br /> ( ) 63-- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> G o ('a(p 10 -9'2 ;7 <br /> HOME or MAILINGADDRESS FAX# <br /> ✓ ( ) <br /> CITY STATE ,/I ZIP — v <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 JoAeuIN <br /> COUNTY Ordinance Codes, Standards, STATE an AL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPS ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT A �tryJTTQ�}r,�Qy• <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 tinII�I,I provided to me or <br /> my representative. P�Y�c �e <br /> TYPE OF SERVICE REQUESTED: RECGl <br /> COMMENTS: • q b 2017 <br /> Gia y")/p,o 0&J1d4 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: /-? .a/_ ./7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: /L-�,. ab / 7 <br /> Date Service Completed (if already completed): SERVICE CODE: Jr' z3 I PIE: 14161 <br /> Fee Amount: r7Q Amount Paid Payment Date ,t ,jl, f, I 7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S' <br />