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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S t�001 �l 2d <br /> WNER/OPERATOR <br /> CHECK If BILLING ADDRESS IT <br /> FACILITY NAME &Yzdw <br /> SITEADDRESS �ol-7�S 5 ly7A A/7-"JC--f I-ArHROP 9533-0 <br /> Street Number Direction Street Name/ CiN Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> 14it - O It FA - 1 700 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> AO 04-7-057 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> G CHECK If BILLING ADDRESS <br /> BUSINESS NAMEC, 1� L PHONE# ExT. <br /> OZ' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP IY <br /> BILLING ACKNOWLEDGEMENT: 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 DO I tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST TE and FEDEPn laws. <br /> APPLICANT'S SIGNATURE: DATE: el / <br /> PROPERTY I BUSINESS OWNER El OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT IS not the BILLING PARTY,Proof of aut Ionization 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED:N# .16011- d <br /> COMMENTS: /� ! �°i✓�r/C RECEIVED <br /> lL�if/ Z°/7 GO w>t�:v .l � <br /> DEC 18 2017 <br /> glyo •�,k✓ s �/Rew'�t✓���dy rs� <br /> I l�l 0 7J MI" ' A1101,1- � , �ENVIRONMENTAL <br /> TM <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: C.5.�rGt d,, EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: .2 G G <br /> Fee Amount: 6 G Amount Paid G o Payment Date /z. /ca. / 7 <br /> Payment Type C(L Invoice# Check# 3 t 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />