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RECEIVED <br /> SAN JOAQUICOUNTY ENVIRONMENTAL HEALTH9EPARTMENT SEP 2 3 2015 <br /> SERVICE REQUEST <br /> EALTH <br /> Type of Business or Property FACILITY ID# SERVICE RE%"IT11SERVIC ES <br /> LfAod <br /> OWNER I OPERATO <br /> CHECK if BILLING ADDRESS❑ <br /> � <br /> FACILITY NAME � �J,I_ nV � � ,p,� �p17, ,JY ` <br /> SITE ADDRESS 3-17 <br /> Z <br /> Street 14L I Direction �C� Sltrost Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> stro.t Number troot Name <br /> CITY t,�/� ,�, �^ -Sea„ i ,� ZIP/ . ? <br /> (�6 <br /> PHONE#1 u V�}';(�/ V%�_ ExT• APN# \ LAND USE APPLICATION# `� <br /> -(310) rI �lU� vq,: '020 2q A- I T'1au <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME SuI��Z PHONE <br /> �/�t �►�' T. <br /> Z7E <br /> HOME or MAILING ADDRESS- 1 ` FAx#l <br /> P 12 ma:1 V1 SN- Ui L c7itp <br /> CITY STATE ZIPq <br /> BILLING ACKN LEDGEMENT: 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,STATf and FEDERAL laws. I <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. PAYM <br /> TYPE OF SERVICE REQUESTED: <br /> �^� �� � /-7$r:!�- a-yrY\9rt RECEIVE . <br /> COMMENTS: Y/.2 9//S-— !/�4 e�/Y��¢v�r� e� r �Ca.0 t�z A�`}++ g— t 4c I r{ t= til/-3 /�r,�{ SEP`G o L U J <br /> "JOAQUIN COU TY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � �Ll , r�/✓�al0&/A EMPLOYEE#: DATE: 9,/J3//S— <br /> ASSIGNED <br /> , J /S—ASSIGNED TO: � �����; �' ✓ EMPLOYEE#: WSJ$ DATE: ;9 P-I <br /> Date Service Completed (if already completed): SERVICE CODE: p P 1 E: !/S/p 7 <br /> Fee Amount: Amount Paid _ Payment Date / <br /> Payment Type Invoice# Check# D, o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />