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SAN JOAOU14 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR r' <br /> CIO ' ` O ` CHECK If BILLING ADDRESS <br /> /0--4 <br /> FACILITY NAME <br /> SITE ADDRESS //) /� <br /> �t2 Street Number irD rection /'/ 2114ystreet Name � 0 <br /> HOME Or MAILING ADDRESS (If Different from Site Address)_l <br /> / LA <br /> S treet Number <br /> CITStreet Name <br /> 6STATE Zip <br /> 12 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. POS DISTRICT LOCATION CODE <br /> ( ) tJ <br /> CONTRACTOR/ SERNqCE REQUEST®R <br /> REQUESTOR ��ry-�yy� <br /> /lC CHECK If PILLING ADDRESS'rJ� <br /> BUSINESS NAL4E PHONE# EXT. <br /> e L <br /> HOME or MAILING AD RESS FAX# <br /> rJj7 ( ) <br /> CITY -3- i/ Za �Z/j STATE zip <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 /> also certify that I have prepared this application and that the work to e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: / / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THER 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 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 a5 It Is available and at the same time It Is provided t0 me Or <br /> my representative. C <br /> TYPE OF SERVICE REQUESTED: �1 �i7L P"MENT <br /> COMMENTS: // it'r-Q t S <br /> RECEIVED <br /> 7X-7 Tl /rsv� w��ry � ��> JAN 0 9 2015 <br /> SAN JOAQUIN COUN <br /> Z , ENVIROMENTAL <br /> / HEALTH DEPARTME <br /> ACCEPTED BY: f `C\I-�v. i EMPLOYEE : DATE: <br /> 6 1 Q <br /> ASSIGNED TO: Le k- ' J EMPLOYEE#: DATE: t <br /> Date Service Completed (if already completed): SERVICE CODE: 3( 5 P/E: 2 L O3 <br /> Fee Amount: 2 6 J Amount Paid Payment Date t <br /> Payment Type Invoice# — _ Check# "qo � Recei ed y: <br /> E,ID 48-02-025 <br /> 07/17/OB R FO;;f>i (Gn_' Zua) <br />