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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c _7V 570 <br /> OWNER/OPERATOR <br /> d ra/ps CHECK if BILLING ADDRESS <br /> FACILITY NAME V[[[ <br /> �o c9 s L 4 fo r-ci o <br /> SITE ADDRESS co / Ur 1� o3 <br /> 7 �/ Street Number Direction �� Street r Citv, ` Z,n Zi Cn_in_ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 7 r/ v Street Number Street Name <br /> CITY C 3 S',; zip <br /> PHONE)1 L/ I EXT. APN# —1 LAND USE APPLICATION# <br /> aU1 <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> J <br /> CONTRACTOR. SERVICE REQUESTOR <br /> REQUESTOR .�� ` e �o r�-lLaS <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> cos 1 rzz n caHOME 2S <br /> 17 � <br /> Or MAI}JNG AD ESS FAx# <br /> l"L7 Ip Ur O� 0()r r `� a c ) <br /> CITY 53 7,,,, STATE ZIP <br /> BILLING ACKN WLEDGEMENT: 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. <br /> APPLICANT'S SIGNATURE:��(L L L L � p���S DATE: <br /> Z27 <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, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is provided topme or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: J en t�' �•Yhr <br /> COMMENTS: <br /> I c sgN�04 2016 <br /> IVIG `� Hegt&0 .p(1 <br /> FJ►r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: -Z, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0/_ P/E: <br /> Fee Amount: I Amount Pai"W130,Dv Payment Date 31--2-171n, 1 <br /> Payment Type Invoice# Check# Received By:6 � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />