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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5F�66-7393 <br /> OWNER f OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILI NAME r .� <br /> U ^ <br /> SITE ADDRESS `l l A�¢}{�/'� r'�1 I Q �S <br /> treet Number Dir�clian r `� OA/f me^u `� Cotle <br /> HOME Or MAILING ADDRESS (If Different <br /> n�from Site Address) <br /> ZLLr-oiv AL)e- Street Number Street Name <br /> CITY76 CALLA/ STATE C zip Gf/al` <br /> PHONE#t ExT' APN# LANG USE APPLICATION# <br /> PHONE#2 ExT, BOS DISTRICT LOCATION CODE <br /> ( G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU STOR <br /> I /1 O/J CHECK If BILLING ADDRESS <br /> BUSINESS NAME L /` 1 i,.v` PHONE# ExT. <br /> (76?) 2Z-7 crZf!Eq <br /> HOME or MAILING ADDRESS FAX# <br /> (( Z3 - L c v ( 6 Le 6 714 Gr <br /> CIN OC S 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 /> 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. t <br /> APPLICANT'S SIGNATURE: ��i Gp�jy/� `/q/�// DATE: I L Z9- ZG/5 <br /> PROPERTY I 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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. 7 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMENI <br /> RECEIVED <br /> DEC'2 9 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY ^^ EMPLOYEE#: <br /> ASSIGNED TO: " � �( �'�\ -Pi vY I L'd EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Sc-D(!t,I PI E <br /> Fee Amount: 0..� Amount Paid /�7� (J Payment Date 2 <br /> Payment Type C, Invoice# t Check# Received By: <br /> . v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />