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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 -, o '7 <br /> OWNER/OPERATOR <br /> I CHECK If BILLING ADDRESS <br /> FACILITY NAME 0���-fJt2 PYb ice— ` <br /> SITE ADDRESS 5�,� cn-,jA.ck TL*.F_ (2o/4-t0 2- <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) &51 <br /> Street Number Street Name <br /> CITY rJ p� C�STATE ZIP C)SZ3& <br /> (�t <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> 12cucl ► 5gto- Oi{2!G /v5—C o- /5 104- r4Uc 9'7 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ('24"1 ) 1 07- 2533 b�( -17 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> M I� CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> D•l,i-u� s rVl v(LPrI^f 33 -Geo l3 <br /> HOME or MAILING ADDRESS FAx# <br /> CITY Lvn STATE C14- ZIP 67S 2-4-t <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 <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: / ` 4—/4- <br /> PROPERTY/ <br /> -PROPERTY/BUSINESS OWNER❑ 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 /> TYPE OF SERVIOPwW#VD: <br /> COMMENTS: R� Z <br /> ` /// I (� I <br /> N O v 2 6 2014 <br /> HEERDEPARTMENT %�� �� � ENVIRONMENTAL HEALTH <br /> ACCEPTED BY: EMPLOYEE#: 4DATE: <br /> 1OASSIGNED TO: /An EMPLOYEE#: /J <br /> Date Service Completed (if already completed): SERVICE CODE: �Z Z P 1 E: 260 <br /> Fee Amount: J Amount Paid "Z 6 C- Payment Date <br /> Payment Type Invoice# Check# ) ?x, r t- Received By: �. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />