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SAN JOAQUI ~OUNTY ENVIRONMENTAL HEALTI- ?PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or,Property FACILITY ID# SERVICE REQUEST# <br /> K s-faaran.t aD02 5f2t�0� o� <br /> OWNER/OPERATOR <br /> M y�L I <br /> t 1 Y r (L CHECK if BILLING ADDRESS O <br /> FACILITY NAME Us h i 6 Ram om- k a us e- <br /> i q <br /> SITE ADDRESS S0- W 4am mtr- Lam- -51*G(L-RQf) <br /> 35y-$ m <br /> Street Number Direction Street Name C' 2i Code <br /> HOME or MAILINGADDRESS Different(If Diffent from Site Address) <br /> -f -7r <br /> v � ��\ I � ( ���r� Street Number � 1 � � Street Name <br /> CITY ST�E� ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (a09) 5qg -96o 1 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r , j <br /> r 1 ( /v,�'� CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' ��' {{{//��� PHONE ExT• <br /> U S <br /> k-16- Rv,"n vie ,204 <br /> HOME or MAILING ADDRESS3s 1 ' FAX# <br /> v�/ H67L m rrL0 ( 1 <br /> CITYS+��o $T T ZIP GI's l <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 <br /> or 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: DATE: d <br /> PROPERTY/BUSINESS OWNER L'J OPERATOR/MANAGER ❑ 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> Ir— <br /> TYPE OF SERVICE REQUESTED: MO CwtsGvf+A-,4j6LA_ PAYMENT <br /> COMMENTS: <br /> RECEIVED <br /> JAN 12 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: O 2 I fp <br /> ASSIGNED TO: V f EMPLOYEE#: DATE: O(/ <br /> Date Service Completed (if already completed): SERVICE CODE: o(.- I P 1 E: (np_ <br /> Fee Amount: Amount Paid Payment Date ( 12 (P <br /> Payment Ty eckl Invoice# Check# q Received By:� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />