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SAN JOAQUIN �.OUNTY ENVIRONMENTAL HEALTH Dt_r ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER!OPERATOR <br /> L CN_ -r-^l -- -- —�---CHECK If BILLING ADDRESS <br /> iCaC <br /> FACIi iry �Ah4E Ni <br /> /AA T I A <br /> SITE ADDRESS <br /> Strect Number Direction Street NameCitv Zi Coca: <br /> _�. <br /> HomE Or I. FLING ADRESS (If Different from Site Address) <br /> I I ` IS <br /> i t I C- <br /> _�� Street Number I .� _.Street Name <br /> CITY rt � �STATE ( ZIP <br /> s �c� c_ � qS '�o <br /> PHONE#11 EXT. APN# [-AND USE APPLICATION# <br /> ��ot his- i3 �.3 <br /> PHONF#2 EXT. BOS DISTRICT LOCATION C)DE <br /> CONTRACTOR/ SERVICE RLQUESTOR <br /> REC�UESTCTR �� ,T� r' -'i-- <br /> 1 "^1 :HECK If BILLING AD:'-RI-SS <br /> I�.� q c-Ng k j 7D1� �>� <br /> BUSINESS NAME S 7 PHONE# ES <br /> XT. <br /> ILU'rE I N C <br /> HOME or MAILING ADDRESS FAX# <br /> 11 a 3 <br /> ti 1 s L) <br /> CITY L C i"\,J J-I STATE ca 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, I <br /> TAt and FEDERAL law:A" <br /> . <br /> APPLICANT'S SIGNATURE: az"c Ctz " DATE: `r I <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorizatir,n to sign is required Title <br /> AUTF OR17ATIOA TO RELEASE INFORMATION: When applicable, I, the owner or operator of i;ie property located at the abowe <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to fl - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It IS provided to me Or <br /> i',y representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: �O kI C(l PL a�rf"IVED - <br /> COMMENTS: <br /> SEP 1 3 2016 <br /> SANO <br /> E ROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �1;)Q('l, � EMPI -(EE#: DATE: ', I <br /> ASSIGNED TO: 4 EMPLOYEE#: DATE: �_ I <br /> Date Semite Co,nplet (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: ,� O� Amount Pair, Payment Date ` <br /> Payment Type t�1F Invoice# — (:;heck# '1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />