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SAN JOAQU•COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ppe of Business or Property FACILITY ID# SERVICE REQUE iz �i.5T R �/ o � r9�� �a�s oa <br /> OWNER/OPERATOR 5�61 <br /> REIV !-.` C CHECK If BILLING ADDRESS <br /> 44 FACILITY NAME 1C Ors FFF--- <br /> 46 1 <br /> SITE ADDRESS / 7e� i_1"_ t n We-r--f <br /> - 0� G�cKT6.J y5a <br /> Street Number pirectlon l� sb¢et Name Clt� _I Cac,,, <br /> HOME Or MAILING ADDRESS (If Different from Site(tddress) �� <br /> " � `6 C,MY Y la Street Number _ <br /> Street Name <br /> CITY STzipZIP ^ Sq �^ <br /> PHONE#1 E'" APN# LAND USE AAPLIC,ATION# Cl�l O D <br /> 9q C)___A Z�D_ (S � <br /> PHONE#2 EXT. OS DISTRICT LOCATION CODE <br /> (apt) 1GG _ <br /> CONTRACTOR/ SERVCE REQUESTOR <br /> REQUESTOR c1g1 <br /> ^\��,� CHECK If BILLING ADDRESS L.tl <br /> BUSINESSNAME \ �^ P NE# EM <br /> HOME or MAILING ADDRESS -\9 FAX# <br /> � � ( ) <br /> CITY STATE ZIP <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 /> 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, STAT DERAL laws. <br /> APPLICANT'S SIGNATURm.E:/---- � T — DATE: IS <br /> PROPERTY/ USINESSOWNE 167' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If AP LICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 JOAQUI14 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the same time it is provided t0 me Or <br /> my representative. �f <br /> TYPE OF SERVICE REQUESTED: -o D ' o,- (,l. " 10 t IVSD <br /> COMMENTS: FIFInE <br /> SEP 16 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROVAENTAL <br /> HEALTH DEIPAIITfME" <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I Cr r._. Z EMPLOYEE#7 DATE: G <br /> Date Service Completed (if already completed): SPRUCE CODE: t?(p /PIE: <br /> Fee Amount: / 9Amount Paid cl T&O Payment Date G . <br /> Payment Type CIC Invoice# Check# <br /> /00 Received By: 7 <br /> EHD 48-02-025 SR FORM Golden Rod <br /> 07/17/08 ( ) <br />