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SAN JOAQWOUNTY ENVIRONMENTAL HEALTH IMPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oc s o✓a 2Qo7-?'20� <br /> OWNER/OPERATOR <br /> r � ^ 12 ^ `0 X G S <br /> FACILITY NAME CHECK If BILLING ADDRESS <br /> G /i <br /> TowP i <br /> SITE ADDRESS // /, ^A 5 Z`jZ/ <br /> 3 Z 2' Street Number /S <br /> Directian C� tr�e'fName V L ' s?LIC4 o'-1 Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 16 <br /> / 5 L s C ,4 L /- Lt/ +V'/} y, <br /> Street Number Street Name <br /> CITY ^^+M .T e �A STATE ZIP <br /> yS3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2G� L/ 06 — 1Go7 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Fla <br /> fe- �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME J O PHONE# ExT. <br /> 1�2Tou--1 v (ZO2) (106 <br /> HOME or MAILING ADDRESS FAX# <br /> 3 06 C, ' FIC4 ZtEi ( ) <br /> CITY 0 c-/< M STATE ZIP 1S Z 0 <br /> 5 <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 /> 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. f <br /> APPLICANT'S SIGNATURE: ;, '-Z - DATE: of/Z 7- <br /> PROPERTY/ <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided to me or <br /> my representative. ,p ^— <br /> TYPE OF SERVICE REQUESTED: 7G <br /> COMMENTS: REICjEiVED <br /> SEF-2 2 2015 <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: �/) U EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed):l SERVICE CODE: kyr PIE:( �L <br /> Fee Amount: 2�� LU Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />