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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE <br /> TO Ob a I I 1 � ���D 7��`T <br /> � <br /> OWNER/OPERATOR I r, <br /> CHECK If BILLING ADDRESS <br /> FACILITY-NAME Os Co M Afc5 — <br /> SITE ADDRESSAtreoethl.mber <br /> f y N /, " Abck oyq q 2� <br /> Direction 1 '1C reetN\a . city,V � Zip Code <br /> HOME Or MAILING ADDRESS (If Different fro Site Address) <br /> /V E I 10 G `5 Street Number Street Name <br /> CITY ��c4o%q STATE „A ZIP q S n 10 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# G <br /> (20q) 922- 60 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (2cl) 248- to q3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE It EXT. <br /> c 81 <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY 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 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:C (S CAI Ct )11c' I�ZZ f/DATE: & <br /> PROPERTY/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, 1, 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 J,)AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time it is provided to me or <br /> my representative. PAYMEERT <br /> TYPE OF SERVICE REQUESTED: Foo6 �o.V)ic,je RECEIVED <br /> COMMENTS: � � � ��� � APR-2 2 2016 <br /> (j (Q SAN JOAQUIN COUNTY <br /> ENVIHOMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: l EMPLOYEE#: DATE: <br /> Date Service Cc.Tnpleted (if a ready completed): SERVICE CODE: v' / P1 1: <br /> Fee Amount: ` Amount Paid �; l_. Payment Date <br /> Payment Type r. Invoice# Check# Received By: C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />