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SAN JOAQUIN COUNTY ENMRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SVS 5E 9V) CF- I I fA00090 <br /> OWNER/OPERATOR <br /> SA <br /> )=;' CHECK if BILLING ADDRESS <br /> FACLRY NAME C =A C <br /> SITE ADDRESSM.y -c-r _ —OrL S 1�O C }CTD► '�S'�bS <br /> Street Number Direction I StreetName city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> 6 '-"6 go (c► 1�1— 02.0 -- 11 <br /> PNONE#Z ExT <br /> JOS <br /> DISTRICT LOCATION CODE <br /> ( ) 00 bI <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR PE:-rE:1?SO w v I u y,0�A 0 L 1 C.S ) NO- <br /> N O <br /> !7 f tis CHECK if BILLING ADDRESS <br /> BUSINESS NAME -510q I./1 P31pExrFAx# <br /> . ,� <br /> HOME Or MAILING ADDRESS '�L S.� ';;>- l� <br /> 6 hl <br /> CITY ��yz STATE ZIP <br /> N p p <br /> u 3111ING ACKNOWLEDGEMENT: 1, 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 /> 1 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 ® a4>1V ,oa_ (� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required riae <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 /> 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: (Qt�S {jI <br /> CORMENTS: (RECEIVE© <br /> APR 102014 <br /> SAN JOAQUIN COUP <br /> ENVIROMENTAL <br /> HEALTH DE1 7 <br /> ACCEPTED BY: ALL EMPLOYEE M 2 6 DATE: N_ /D 4- <br /> ASSIGNED TO: EMPLOYEE#: �f_ DATE: 'fes <br /> Date Service Compl d (if ahead ompleted): SERVICE CODE: 3 PIE: 7303 <br /> =ee Amount: 41 %g b , &-3 Amount Paid � Bfl Payment Date V 10 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> n7m wnA <br />