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SAN JOAQUIN%NTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pry skOb75i�U <br /> OWNER/OPERATOR E] <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> a I, D(a o1 <br /> SITE ADDRE S 11700 --jiv\ �(XiCQS�-O � ,S-sS(Q <br /> Street Number Direction Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> r Street Number Street Name <br /> CIN '1P�r <br /> PHONE#1 EEXT.11STATE ZIP <br /> r-� ` APN# LAND USE APPLICATION# <br /> (01CR 55oc` ) 2 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> EQUESTOR <br /> Z CHECK If BILLING AUDRES <br /> SINEss NAMEI EXT. <br /> HOME or MAILING ADDR S v FAX# L-1\ <br /> ::)Y- <br /> CITY Cn 5 STATE ZIP <br /> BILLING ACKNOVVLEDGEMENT: 1, 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. <br /> APPLICANT`S SIGNATURE:;G—V,, DATE:_(0/30//(2 <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 a5 It IS available and at the same time it IS provided t0 me Or <br /> my representative. `, <br /> TYPE OF SERVICE REQUESTED: C,� RECEIVED <br /> COMMENTS: <br /> JUN 3 0 2016 <br /> SANNVAQUIN ROMENTCOUNTY <br /> AL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE if: DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: a� <br /> Fee Amount: J Z?V d Amount Paid l 3 ilfl'C`90 Payment Date 143 0 /(g <br /> Payment Type / y(�_ Invoice# Checit-# 0 3�7� I Received By: Z <br /> nri <br /> EHD 48-02-025 . SR FORM(Golden Rod) <br /> 07117/08 <br />