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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID= SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> l.L <br /> �^, L CHECI<if BILLING ADDRE55O <br /> FACILITY NAME �J <br /> SITEADDRESSPdy � <br /> Sheet Number Direction Street Name Ci Zip Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> \ Street Number Street Name <br /> CITYSTATE ZIP <br /> PHONE#1 G.41� Exr' APN# LAND USE APPLICATION# lJ. <br /> (510) IiM- X11`7 <br /> PHONE#2 ExT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> J� CL— <br /> CHECK If BILLING ADDRESS <br /> T L r� \� PHONE# Exr. <br /> BUSINESS NAME \�� a tV`,�` ^'\""S �o� �QO Sb ''t S - � 7 <br /> HOME <br /> iio--r/rM�,AIL ADDRESS �f\1T` c FAX# <br /> \\\Ocv �CeW ( ) <br /> CIN STATE Qi- '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 app' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST and FEDERAL I <br /> APPLICANT'S SIGNATURE: _ DATE: <br /> PROPERTY/BUSINESS OWNERLV O TOR/MANAGER ❑ O HER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the wNG FART Y,proof of autho - atfon to sign is required Title <br /> AUTHORIZATION TO RELEASE IN RMATION: When applicable, I, 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 JOAGUI.J COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. / " <br /> TYPE OF SERVICE REQUESTED: GA04w1+-'0.,of PAYMENT <br /> COMMENTS: R <br /> MAY 0 3 2016 <br /> SAN EJO R U�7p1Ell AL 141 <br /> HEALTH DEPA"iTME <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: %cia� pQc�Ya3� EMPLOYEE#: DATE: <br /> Data Service Completed (if already completed): SERVICE CODE: 'C�—o P i E:1,tQDZ <br /> Fee Amount: Alu-ov Amount Paid - � ���; .; Payment Date i <br /> Payment Type 4.`z,�_'IL. Invoice# Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />