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SAN JOAQULr COUNTY ENVIRONMENTAL HEALTAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> iq A'--U0 5g- M 7 J <br /> OWNER/OPERATOR ` V 1 <br /> 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME � � , `� MMA <br /> Dc) <br /> SITfEADDRESS ��/�/� I �� /A \ 1� �An��� 1053 <br /> 1 Street Number DirectionStreet Name ,"C v Ci i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> �G�> 59- oal®e <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> v\0� '1 <br /> V \ CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 PHONE# ExT' <br /> HOME Or MAILING ADD �S In � �`v,� ('°'X#Ile ) <br /> CITY a -�oie jJ`c/ STATE ZIP 9533 <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 <br /> or 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. <br /> APPLICANT'S SIGNATURE: DATE: �/- 7-✓� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviromnental/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. <br /> TYPE OF SERVICE REQUESTED: REC <br /> COMMENTS: A ri p O 7 2015 <br /> SAN JOAQUIN COUNT) <br /> EVIRMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: n EMPLOYEE#: 2�OZL DATE: Li/'IM <br /> ASSIGNED TO: ( e,0 COft <br /> EMPLOYEEM LZ DATE: Ii 1`7 JIS <br /> Date Service Completed (if already completed): SERVICE CODE: OIC P/E: Q(Q <br /> Fee Amount: O Amount Pai a(D�,b Payment Date 7 S <br /> Payment Type Invoice# Check# Recel ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />