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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'p I �� bad ��I�� �2cb��o /g <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NA TT CO` C ti <br /> SITE ADDRESS S �QU <br /> /,/ <br /> ' 'l S Street Number Direction SV at Name C ZI Cod. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ----- <br /> D� 2IQZ Scree Number Street Name <br /> STATE ZIP <br /> CITY L (A <br /> \(1 L ~ <br /> PHONE#1 APN# <br /> LAND USE APPLICATION# <br /> �T' <br /> ( ) Cl `l 1- Oyu l <br /> PHONE#2T' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADORES <br /> L <br /> PHONE# W. <br /> BUSINESS NAME G <br /> t <br /> HOME or MAILING ADDRESS FAX If <br /> 300 F— Z �4 . 2 ( ) <br /> I` CITY STATE /, ZIP /7 S <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> - 9� DATE: -LIZ I re <br /> PROPERTY I BUSINESS OWNER. <br /> E OPERATOR I MANAGER IJ OTHER AUTHORIZED AGENT 1:1 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tire <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 /> 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: 6,-& lL PAYMENT <br /> COMMENTS: <br /> aDEC 12 2016 <br /> STAN JOAQUIN COUNTY <br /> ENWROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �1 EMPLOYEEM DATE: <br /> ASSIGNED TO: H1� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E:/4'Q <br /> Fee Amount: 1Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />