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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtfrARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> (�a <br /> {A0002-76'12 Sk007gC&b <br /> OWNER I OPERATOR _ <br /> CHECK If BILLING ADDRESS <br /> � lC4r- Cwt G�LIV1l�a <br /> Falry NAME <br /> $ITE DDRES�S `" t �Y Q-C 1a f� so yx i(-/r( <br /> SQ Slreef Number Direction V� l Street Name �I `"'d�� <br /> HOME)1Or�MAILING/FIDRESS (f !f\ferent,fro1in Site Address)C..J1. /'� <br /> -� \O L(/ J 1 Street Number , 19 Street Name <br /> CI STATE zip <br /> PHONE#I EiT. APN# LAND USE APPLICATION# <br /> (� <br /> -51-A(V & <br /> PHONE#2 E T* BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ S_ERVICE REQUESTOR r <br /> REQUESTOR n ���� CHECK If BILLING ADDRESSC <br /> BUSINESS NAME lJ, PHONE# E.T. <br /> d— <br /> HOME Or MAILINNG A # <br /> DDRESS FAX <br /> I MSA ( ) <br /> CITY / F✓ An f <br /> . -) ✓1To STATE ZIP��/1 Tl/' <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorizedagent 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinan.'e Codes, Standards,STATE and FEDERAL S. <br /> 1 a <br /> APPLICANT'S SIGNATURE: CAf jj,'� P9JY(P= _ DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APP''CANT 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 Pie 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: <br /> COMMENTS: PAiMW <br /> RECEIVED <br /> JAN 27 2016 <br /> SAN JOAHUMENTOUNTY <br /> AL <br /> _ _. . —._ ._..—. yy ptp <br /> ACCEPTED BY: EHIPLOYEE#: TZJ T/2 (� <br /> AsSICNED TO: ` fft' t14 ` EMPLOYEE'IFi DATF: G(1 �2- I(� <br /> Date SPvice Completed (if already competed): ' SERVICE CODE: SG O PIE i&c-z <br /> Fee Amount: �iO ,VV Amount Paid � Payment Date <br /> I Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />