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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHSEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />/ A 0 <br />SERVICE REQUEST # <br />c3iZe0 -77---f-171(--) <br />OWNER / OPERATOR , <br />PIA \ \t!"1 \gA \en(Itine) <br />CHECK if BILLING ADDRESS a <br />FACILITY NAME --ri - 1,y1..e, 0 <br />SITE ADDRESS 9)10 <br />Street Number Direction <br />• u-FA \ 7c-eliJdr I-eX 0 g- . <br />Street Name <br />(-,-- \- 0 -\ <br />Citv Zip Code <br />Or MAILING ADDRESS (If Different from Site Address) Floti_ <br />1---1 0(2 <br />E <br />Street Number <br />9 UniOUZA - \19 v2_ . <br />1 Street Name -1 0 Joat\lAck \ - <br />CITY STATE ZIP <br />0 iijc <br />PHONEr <br />°9e ) -25 5 ---2_1E <br />EXT. APN # <br />1 ill lq ()°C6 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />C C.' 7) <br />LOCATION CODE <br />0 1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ,i) , , , <br />Ck I t,\I &CI WI/10(UL CHECK if BILLING ADDRESS <br />BUSINESS NAM E...-\.n O NI s)...., -T, 0 1 alitt, <br />PHONE # <br />(20(1) 2-5---2- \ <br />Exr. <br />HOME or MAILING ADDRESS <br />1 (1---r—) ' Orick-Q_A)So D'C--- • <br />FAX # <br />( ) <br />ci rv DCA Y--6(6( CQ-- STATE c A\ zip et cc) 1 <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 OT <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. <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0/ OPERATOR! MA GER OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize ,he release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUN1 '1 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: c-Orx-\ Coilc---)0A4a ICY) + 1_ i,P,AYMENT <br />, ENTS: "CFIVED <br />CA\anC‘ c o C c-u3oef i-) fp Nov 0 4 2015 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: C .‘ (-e.k EMPLOYEE #: DATE: k , .i4_ is- <br />ASSIGNED TO: Duk icA7,..(A. EMPLOYEE #: DATE: i ) - Li - ) <br />Date Service Completed (if already completed): SERVICE CODE: 0(0 ( PIE: nee -D__ <br />Fee Amount: <br />1-2--X)°° <br />Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />jjVV1 Zj2----IDATE: N41 \.) <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08