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SAN JOAQUINflUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M3037- S1'Zua�1 X5-7-2- <br /> OWNER <br /> 5"72OWNER/OPERATOR <br /> CHECK If BIWNG ADDRESS <br /> I FAcftm NAME iqLJ1 <br /> SITE Ta <br /> treetNumber I dution Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Slraet Name <br /> CITY STATE ZIP <br /> PNONE#1 i ExT• APH# LAND USE APPLICATION# <br /> PHONE R BOS DISTmCT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR• <br /> CHECK H BILLING ADDRESSFf. <br /> BUSINESS NAME — <br /> HOMEAl G FAX# <br /> ( l _ <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 <br /> or activity will be billed to me or my business identified on this form. <br /> I also certify that I have prepared this appy ation a d t the w to be ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E and A S. <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUsiNEs5 OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGEIN'T <br /> ff APPLICANT is not the BILLING PARTY proof of authorization to sign is require4P, Title <br /> AUTHORIZATION TO RELEAS 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: (A ST lzvwv i+ PAYMENT <br /> pvN�I Cwt <br /> M G 1 rT <br /> COMMENTS: RECEIVED <br /> AUG 2 3 2016 <br /> SAN JOAQUIN COUNTY <br /> a_NVIIROMENTAL <br /> HLALi H DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: O Z 3 I 0 <br /> ASSIGNED TO: \(i( )e G�(�/ EMPLOYEE#: DATE: g <br /> Date Service Completed (if already completed)" SERME CODE: s C,1% I PIE: 238 <br /> Fee Amount: "�- Amount Paid LA 11. Payment Date (P <br /> Payment Type U,C _ Invoice# Check# SgrJ� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />