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SAN JOAQUIN�UNTY ENVIRONMENTAL HEALT�PARTMENT <br />SERVICE REOUEST <br />Type of Business or Property <br />FACILITY ID # <br />F�' ,3 <br />SERVICE REQUEST # <br />c�i2 <br />G,4SOL/,vE 6 DISPGVS/A FWI�t' <br />�� <br />-C:����� <br />OWNER/ OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />iocnStreet Number I Direction <br />V Street Name' <br />city_ T9,S <br />ZfJ Code <br />ME or MAILING ADDRESS (If Different' from e Address) <br />:�(DC, Street Number <br />Street Name <br />)TY <br />STATE ZIP <br />PHONE # ( EXT.APN <br />( ) <br /># <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />rOS DISTRICT <br />LOCATION CODE <br />�ri�Tmn A rmnII3 i 4QUIQX7Yr- 1QVn11TT4Z'Tf112 <br />1 I Vl\ / k7iil\ ♦ .fit. i'J A,%,-" <br />REQUESTOR CHECK if BILLING ADDRESS W <br />BUSINESS NAME PHONE ExT• <br />TAA02LO 1P <br />HOME or MAILING ADDRESS <br />CITY ✓9V'VA \Me, STA y6 �_ ZIP Cr>l;n <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 <br />or 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 an EDERAL laws. <br />APPLICANT'S SIGNATU DATES:: ('t—l�_2� « ��i <br />PROPERTY / BUSINESS OWNER OPERA R / ANAGER ❑ OTHER AUTHORIZED AGENT yl� Jts+G S MAGE°, <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is require <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JAN' 2 2 2016 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE M DATE: <br />Date Service Completed (if already completed): SERVICE CODE: l PIE: 2-14-2 16 <br />Fee Amount: Amount Paid Payment Date 'ZyJ'le <br />Payment Type G, Invoice # Check #W41 -11711P Received By: 146 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />