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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAR O 4 2016 <br /> SERVICE REQUEST ENVIRONMENTAL <br /> Type of Business or Property FACILITY ID # I tC A t Tu nF SART SNIT <br /> SERVICE REQUEST # <br /> Doo ��Bb <br /> OWNER / OPERATOR SJL�9oo7y3L� ` /^ �a \� <br /> FACILITY NAME VV CHECKIf BILLING ADDRESSI� <br /> SITE ADDRESS 11.16-1 <br /> ' �/T�-�/II <br /> Sreet Number Dir ctlon v " " ` ' `� ` V� V " I ^ 9 <br /> RZI <br /> HOME or MAILINO ADDRESS (if Different from Site Address) . Street ame <br /> zl ceHe <br /> " IT Street Number Street N <br /> STATE zip <br /> NHDNE #t Ezi• APN # <br /> ( S � \ I O� I ,�/n LAND USE APPLICATION # <br /> PHDNE #'1 V � Enr• <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> V` CHECK If 8 LI G ADORES <br /> BUSINESS NAME � 'n �� ^ ^ <br /> HOME Or PHONE 4 Ent <br /> MAILING ADDRESS r? 1� � /t �� owbi <br /> ( U Y9 l� FAx # <br /> CITY ( ) <br /> v STATE <br /> BILLING ACKNOWLEDGEMENT' I, the undersignedness ZIP q 7 _ ' <br /> acknowledge that all site and/or project specific ENVIRONMENTALDHEALTH DEPARTMENT hourlychargesrator oassociatedeWithgthis Project lor <br /> activity Will be billed to me or my business as Idd tired on this form. <br /> 1 also certify that I have prepared this appli i nd that the ork to be performed Will be done In accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT IT F OERAL Is W§ <br /> APPLICANT'S SIGNATURE: �1 ( Co <br /> PROPERTY / BUSINESS OWNER ❑ OPERAT R / MAMA ❑ OTHER AUTHORIZED AG EN <br /> DATE; <br /> If APPLICANT is 1101 the 81LLING PARTY proof Of atlthorizaflon to sign is required <br /> AUTHORIZATION 70 RELEASE INFORMATION; When Title <br /> 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/sile assessment information <br /> 10 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time �Q <br /> my representative.. me It Is provided me or <br /> N <br /> TYPE OF SERVICE REQUESTED; I I / qY <br /> COMMENTS; F� T <br /> y/ <br /> MCNNWC � <br /> ACCEPTED BY: <br /> EMPLOYEE #: DATE: ( Br I• I)b <br /> ASSIGNED TO: y(�7. 0 ' vj�Ar ICA <br /> EMPLOYEE #: DATE; a3 o�,II � <br /> Data Service Completet ded (if already completed): - <br /> SERVICECODE; PIE; <br /> Fee Amount: <br /> � � PaymentDate 3 <br /> Payment Type �54i Invoice # Ch # ��� <br /> Rece ved By: <br /> EHD 48-02.025 <br /> 07/17/08 SR FORM (Golden Rod) <br />