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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> FA NA Q <br /> SITE <br /> tADDRESS <br /> tr ¢(Number Direction eet Name CI I Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONEY1 Ear' APN# LAND USE APPLICATION# <br /> i1 - Ic17U5 <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�Ql/�/`�a �r\c CHECK If BILLING ADDRESS <br /> PHONE# Ear' <br /> BUSINESS NAME KAs �0 C.T O 4 S <br /> HOME Or MAILINGI _14DDREfSS FAX# <br /> JV Vv — -� ( ) <br /> CITY STATE r OD ZIP C)j <br /> I <br /> BILLINGACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge Shat 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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU �� DATE: Q aSr U -I <br /> PROPERTYIBUSINESS OWNER OPERATOR I 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess r�jpformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon aS it is available and at the Sam e time It IS 10�t f, <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: j--� C' 1 t' (4-rA / <br /> COMMENTS: p � JOAQU <br /> 2017 <br /> "iai ]Q� f T �LA:�'J EAt OEPgR M L <br /> ACCEPTED BY: n / EMPLOYEE#: DATE: "LTJ- <br /> ASSIGNED TO: ,� T,, EMPLOYEE#: DATE:q---*? <br /> Date Service Complete already completed): SERVICE CODE: Cj 4; PIE: �. <br /> Fee Amount: G " CY Amount Pain /`' Payment Date �S <br /> Payment Type �:• Invoice# Check# <br /> EHD 48-02-025 <br /> 6A �V gQ n O 16 <br /> D SR:RM(Gold Rod) <br /> Cp (�rJ(/ <br /> 07/17/08 1 <br />