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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST It <br /> .S b67 '�ic'3 <br /> OWNER/OPERATOR <br /> E— ( EN7 / � CHECK If BILLING ADDRESS <br /> FACIL12 NAME O .� <br /> Ge <br /> (J <br /> SITE ADDRESS <br /> A / <br /> V l�1 I 7DS <br /> � 1 beet Number Direction t ` �e�me^ <br /> HOME 01"MAILING ADDRESS (If Different from Site Address) <br /> ZLL7o Aue— Street Numb r Street Name <br /> CITY STATE ZIP <br /> S Zf� <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t 6 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU STOP /� <br /> I lV On CHECK If BILLING ADDRESS <br /> BUSINESS NAME /U /L— ,.` PHONE# EXT. <br /> L I I(J 215ZZ <br /> HOME or MAILING ADDRESS FAX# <br /> (( ?-3 - l; c - v (Zr,9 6 <br /> Clry C'ToC C STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property 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. If <br /> APPLICANT'S SIGNATURE: ( GQ�y/, �g�/J DATE: I Zq- / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof Of authorization t0 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. n y /1 <br /> TYPE OF SERVICE REQUESTED: �!� v�/I U e <br /> COMMENTS: <br /> DECEIVED <br /> OEC 2 9 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVINOMENTAL <br /> ACCEPTED BY ^ EMPLOYEE <br /> ASSIGNED TO: EMPLOYEE#: DATE 1 yGl <br /> Date Service Completed (if already`completed): SERVICE CODE: S,LO(V) PIE: I��3 <br /> Fee Amount: Amount Paid 3� d v Payment Date I2,�9 // �-' <br /> PaymentType C Invoice# Check# Received 6y; <br /> . v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />