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SAN JOAQUI&,,,.,OUNTY ENVIRONMENTAL HEALTH,,,WPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (524 s0/t`1L �K�i �I i�A?��IBI �SZ b --1 � C(> 3 <br /> OWNER/OPERATOR <br /> CHECK NBILLING ADDRESS <br /> FAcu"NAME /// IL /� <br /> /q n LI (, <br /> SITE ADDRE <br /> SS N eA/,, Lln�i,./ a•�p(,�G rO''t 9�7 �`^"7 <br /> /4 Sbcet Number /'1�j./l $ rT ry CRY a2aC <br /> 90 <br /> HOME Or MAILING ADDRESS (N DNfemnt from Site Addrose) NumG <br /> Street ber me VED <br /> Ctrr STATE LP <br /> PHONE#1 E■* APN# LAND USE APPLICATION# N 014 <br /> (Jnr) OG 6 'G 36 ENVIRO <br /> PHONE#2 En. BOS DISTRICT LocA R HEALTH <br /> ( ) p' ES <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> —A-kn" CHECK N BILLING ADDRESS <br /> BUSINE NAME CPHONE# En- <br /> HOME Oma( AILING ADDRE �� FAX# <br /> J 2O-IGO ( ) q t <br /> CITY K me i-S I' ' i STATE C W ZIP i V W// <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. y <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERAT9 MANAGER ❑ OTHER AUTHORIZED AGENT" �QnT2/u/"�`L <br /> I,f APPLICANT is not a BILLING PARTY proof DJ authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH rPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. L- <br /> TYPE OF SERVICE REQUESTED: 2/:rt$ -7- <br /> COMMENTS: <br /> COMMENTS: PA <br /> RECEIVED <br /> NOV 2 6 2014 <br /> TAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: yV n , 1 EMPLOYEE#: DATE: 1 /O <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (N elreedy c pleted): SERVICE CODE: (el <br /> Fee Amount: O ount PaI 3 D 90, D Payment Date <br /> �---- Ams 0 <br /> Payment Type Involve# Check 0 Z( 5-.J (. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />