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SAN JOAQUIN�ICOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IID# SERVICE REQUEST <br /> � 1 S2CA7�)ly� <br /> OWNER/OPERATO <br /> CHECK((BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Direction Street Name L`Z7i JCoEeYJ <br /> HOME or MAILING A111)SS ( 'fferent om Site dress) y�� <br /> L Iskr Street Name <br /> CITY — STATE ZIP <br /> PHONE#t 0 EXT. APN# LAND USE APPLICATION# <br /> (s )7 -43 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (26T5) 7L — 114'q6 11 <br /> CONTRACTPR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK((BILLING ADDRESS <br /> BUSINESS NAME `n I' PHONE# — ExT' <br /> HOMEOr MAiyNG ADORES r LY.Y FAX# <br /> �1 L10 ( ) <br /> CITY ATE ZIP ,5 7 <br /> BILLING ACKN LEDGEMENT: 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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQU <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> CAPPLICANT'S SIGNATURE: �J '�57 �Ap/a DATE: <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization t0 sign is required Title <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 tl�l@it is ProovNT to me or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: SEP 17 2015 <br /> c�ZanQ� O o Tref Sh SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: - /7 / <br /> ASSIGNED TO: I I / r ` EMPLOYEE#: DATE: J /7- /'�> <br /> Date Service Completed (if already completed): SERVICE CODE' 1 1 PIE: Q a <br /> Fee Amount: I C� Amount Paid '� -:3: U ) Payment Date 17 ( "— <br /> Payment Type S Invoice# Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden R <br /> 07/17/08 <br />