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r--% <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER j OPERATORl� <br /> � I � /75;5 e <br /> �r CHECK If BILLING ADORE55 <br /> FACILITY NAME Q <br /> SITEADDRESS 705 yUs e w+,l-e � i -e <br /> Street Number Direction Street Name C'Ity Zi Code <br /> HOME Or MAILING Aot)RJESS (If Different from Site Address) <br /> 5--7 e Street Number Street Name <br /> CITY5 I n / SKATE ZIP 9 5 7 <br /> 0 <br /> PHONE#1 Cf� ! !" Exs. APN# iLAND <br /> USE APPLICATION# <br /> VPH #"c EXT. BOSDISTRIC LOCATION COOS <br /> � ON /finn cc RW E P Err 77 TR <br /> REQUESTORV�y 1`./ �S� �/ <br /> r I CHECK If BILLING AGdRE55 <br /> BUSINESS NAMEPHONE# ExT. <br /> Q V) C' d SaYket 2,g 15 - 3 3 �S <br /> HOME or MAILING ADDRESS FAX# <br /> o C.a ►h I k P, cu (zol) <br /> CITYoo-f`em STATE ZIP <br /> BILLING ACKNOWLEDGErWENT: 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: fj�4 " IJ4S S-e DATE: <br /> PROPERTY/BUSINESS OWNEIk " OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT ❑ <br /> tf 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 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: PAYMENT <br /> � i <br /> COMMENTS: <br /> a hb Uf- 00-a C UC - PQA P, JUL 14 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7V_ <br /> ASSIGNED TO: LIn EMPLOYEE#: DATE: —7_J�- f& <br /> Date Setvico Completed (if already completed): SERVICE CODE: �� PIE: Lob I <br /> Fee Amount: �i Amount Paid V v Payment Date m 7 <br /> PaymentType C Invoice# Check# Received 8y: <br /> U <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07117!08 <br />