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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Tv�` kc, 50 S(z6b'l�$� <br /> � <br /> OWNER/OPERATOR PLa1-c3 INC!- <br /> CHECK If BILLING ADDRESS E]G--mCo K�Pont 'T��c�c <br /> FACILITY NAME gn-766 I/94 n/ -r�vC� /Cl-tZ9 // e <br /> � - <br /> SITE ADDRESS ^rFAAC (�\P6 6?,S 3 U. <br /> /O a�. E. Sbeal Number Direction Street Name CI Zip Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> O_ co . r4 street Number Street Name <br /> CITY Po STATE (i ZIP n S 7 ) �. <br /> � r( �t-� —I b <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# <br /> ( '05) tgS (9 - 7117 2(0)O�01)q <br /> PHONE#2 ETT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR li J CHECK If BILLING ADDRESS <br /> BUSINESS NAME /� t✓I 'I�7 1 POtq go <br /> aC fL_1(2_(Z PHONE# � - � -7 J <br /> Ems. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY \U VA STATE ZIP \�3 /- <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 /> 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 FEOE j.laws. r^ <br /> /APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MAN GER ❑ OTHER AUTHORIZED AGENT ❑ <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 /> t0 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. �c <br /> TYPE OF SERVICE REQUESTED: /EC <br /> COMMENTS: M,Ay 0 <br /> 2015 <br /> SAN j�QUIN <br /> MEq�Ny OM RAS <br /> ACCEPTED BY: EMPLOYEE#: DATE: J / <br /> ASSIGNED TO: EMPLOYEE#: DATE�jj <br /> Date Service Completed (if already completed): SERVILE CODE: 01C) P/E: � <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />