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r r <br /> SAN JOAQUIN"�POUNTY ENVIRONMENTAL HEALTH "EPARTMENT <br /> 1-= SERVICE REQUEST ..r <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SVS sE 9 Vx CF- 5Apo6g 10 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> SA <br /> FACILITY NAME J C � C )'SA C TY <br /> SITEADDRESS <br /> icyfff <br /> }�Y -� 5-r-p C '�'pj� 7,5-q b,� <br /> 2�/ Street Number Direction Street Name ✓C.._ City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number7 Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# ` " LAND USE APPLICATION# <br /> 237 1967- 6 G o G �')- t o <br /> PHONE#T EXT. BOS DISTRICTLOCATION CODE <br /> ( ) 001 If <br /> CONTRACTOR / SERVICE <br /> REQUESTOR <br /> REQUESTOR PE: r��SQ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME P <br /> SA M' <br /> ic, 3 2 3 — l�-S- <br /> HOME or MAILING ADDRESSD O tJ L FAX# <br /> �J P b)3-Z3-3 C C;>-& <br /> CITY y� w/ j STATE CA ZIP p Q <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 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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT R L'C7/1lTJQ�C3'r7 <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: S (Ol.s 6t <br /> COMMENTS: RECEIVED <br /> APR 102014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMEN(r <br /> ACCEPTED BY: M EMPLOYEE#: -7c) DATE: ,! 4- <br /> MAI v /D <br /> ASSIGNED TO: + r EMPLOYEE#: C DATE: 'f <br /> Date Service Compl d (if aireadompleted): SERVICE CODE: IU 3 , PIE 2303 <br /> Fee Amount: 41 su , CN Amount Paid B� Payment Date 'I 1 d <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />