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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C�nE�z wiz(%1 4 49 <br /> OWNER I OPERATOR 44 I KE .rte/0 r, T.\ 0 <br /> FI.JI��J N CHECK it BILLING ADDRESS <br /> FACILITY NAME _,. / <br /> FITEADDRESS (�� W N/ OSw"'"e-7)z_ ulkTh/2Up '�S .730 <br /> _ _Street Number pirection / Street Name city ZI Code <br /> NOME Or AAILIN�GADDRESS (If Different frovl Site Address) <br /> �V�t• '>UX 5iiU L Street Number Stree Name <br /> ry <br /> C' -A r//G.f�(_ STATE _ ZIP <br /> I <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> g05) 5-clS'=-F{aa CD?0 <br /> -0s <br /> PHONE#2 T BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR O S l r C o ref U 1.��� <br /> ll"v C. CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# r/ ExT. <br /> D0C � tJ L � ?rv <br /> HOME Or MAILING ADDRESS fjD `J� (i �•���/ FAX#q PO {� (� f `7 ( ) <br /> CITY –/rupt-0 UC 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 ;he work to be performed will be done in accordance with all SnN JOAQUIN <br /> CO.INTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� DATE: ! o Z I�j5 <br /> IIS�II <br /> � <br /> PROPERTY I BUSINESS OWNERZ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ' <br /> /(APPLICANT Is not the BLLLING 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 abo✓e <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 DEPARTMEJT 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: A/ t # uL tXt- <br /> RECEIVED <br /> �1-//5 <br /> G?LIP <br /> / .fin <br /> DC OCT11 2015 <br /> SAN JOAQUINCOUNTY <br /> FNVIROMENTAL <br /> ACCEPTED BY EMPLOYEE#: HEALTH DEPART —I <br /> TE: p <br /> ASSIGIIED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />