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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L._r'ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />`"rGU� ISP <br />FACILITY ID # <br />SERVICE REQUEST # <br />OCT 2 0 2017 <br />SAE JOAQUIN C UN Tw <br />P71G S�odT. <br />HOME or MAILING ADDRESSFAX <br />21 � � �er C-�i�rv-►� <br />-00 <br />ISf t2 q <br />OWNER / OPERATOR T A 1 <br />'V1 I 7 ,it' /, ! (a� <br />, IG�J Gr <br />/ I / <br />„/ M /t �i j/ CHECK If BILLING ADDRESS <br />vl Wr <br />FACILITY NAME C �'�/ <br />DATE: 1 0/ -2,9 // <br />Date Service Completed (if already completed): <br />SITE ADD ESS � <br />� <br />PIE: <br />Fee Amount: l 2 <br />Amount Paid <br />t G 2 W <br />"[ <br />Street Number <br />Direction <br />treet Name <br />ci <br />Received By: <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #11 EXT. <br />�0 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ���jj} �7 EXT. <br />(412m- -/V o � � <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR L b ^ / , <br />CHECK If BILLING ADDRESS <br />/!(�(�� <br />BUSINESS NAME <br />A 61aS 1 fvo� <br />OCT 2 0 2017 <br />SAE JOAQUIN C UN Tw <br />P71G S�odT. <br />HOME or MAILING ADDRESSFAX <br />21 � � �er C-�i�rv-►� <br />�rtV� <br /># <br />c ) 3C j �o / � <br />CITY PX4Kf� <br />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 />also certify that I have prepared this application and that theork to be p med will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, d FEDERAL lay <br />APPLICANT'S SIGNATURE:` DATE: / <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER -GTHE UTHOR Imp 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 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 time It IS provided to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: - <br />New y <br />N S <br />COMMENTS: <br />OCT 2 0 2017 <br />SAE JOAQUIN C UN Tw <br />ACCEPTED BY: <br />EMPLOYEE #: MEA <br />T"Ali'pM N I <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: 1 0/ -2,9 // <br />Date Service Completed (if already completed): <br />SERVICE CODE: Z/ <br />PIE: <br />Fee Amount: l 2 <br />Amount Paid <br />t G 2 W <br />Payment Date <br />Payment Type v i 5 <br />Invoice # <br />Check # O a-7 L� l , <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />