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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3& ----J A fX tja,9 ( :0 5260E7a� <br /> OWNER/OPE TOR �- /' r12 <br /> t QNF.CK If BILLING AGpREa^S�J. <br /> FACILITY NAME At Ice— 1 tC� l 1� <br /> SITC�}`eIDJD'R7ESS <br /> J •/ _..ec rvbmber OlreJtni Stroet Namr_ t1 (`�-CCItvl`, ".I[io Cone J <br /> HOME Or MAILING ADDDRRE'7S (If DiHerert Ernr.,Site Add/ress) /� <br /> �_ AIS ;r l(D L(� L�1 VAC_ Stree.Number <br /> CITY C1 Ly— <br /> STATE /,„ zipgS 20 <br /> PHONE#t v`Cl EXT APN# LAND USE AAPi`PLIOA-EoiJ?? <br /> PHONE#Z OC Ez'. SOS DISTRICT LOCATION CODE <br /> ( 2 i -l�. <br /> CONTRACTOR/ SERVICE REQUEST'OR <br /> REQUESTORt �` <br /> �V IQ-- CHECK ItBILLINGADDRESS <br /> BUSINESS NAMEZA I PH E# EZT./c' Ut +� � ,� qs�-ops 7- <br /> HOME or MAILING ADC.CES FAX# <br /> ZS2C 1 0� z Gt ( <br /> CITY STATE /%Q zip 205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> also certify that I have prepared this applica' n and t Jat 1e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY"Ordinance Codes, Srandards, STA ,phd FE aws ''� <br /> ia'r'rLICAN I'S SIGNATiiRE: DATE: �I �-Zo(7L '—�- <br /> ROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANTpnot 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 propeat the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environme AliWant inform-tion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the S tjgW.ihy��ded to me of <br /> my representative. I �(W(W�.lyiGG������ <br /> TYPE OF SEPA110E REQUESTED: (� I �� fGg u 1 2017 <br /> COMMENTS: OWMJAI ' f G <br /> SAN JOAQUIN COUNT( <br /> ONMENT L <br /> WEALM09 nRn+ <br /> ACCEPTED BY. EMPLOYEE#: DATE: <br /> As^-(,NEO TO: ' I _ AA,li L• EMPLOYEE#: DATE: �. f <br /> Date Service Qomplete (if already completed): SERVICE CODE: ®(e I PIE: <br /> Fee Amount I DU Amount Paid i S r L' gent Date r> _ 1 -- <br /> Payment Type C Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �w <br />