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SAN JOAQUI14 COUNTY ENVIRONMENTAL HEALTH D,.-ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME r" �� <br />S/7��K%au S It�a*fl>FR) uL <br />FACILITY ID # <br />HOME Or MAILING ADDRESS 2 /�, ,' ^ I� a -T r L <br />O ) J f � O i'V U fs � �.�1 L r <br />SERVICE REQUEST # <br />OWNER/OPERATOR (\� /7 <br />IS U.'0 r E'qb C //'�/(w�L( CHECK If BILLING ADDRESS® <br />FACILITY NAMEn,G�C-%�� <br />SITE ADDRESSa <br />SMeel Number <br />Direction <br />/ SM¢¢t Name <br />SAN JOAOUIN COUNTY <br />CIN 7 U <br />Zip Cod, <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />SUeet NJum7ber <br />"_ �XAUC <br />/(r �+Stre Name <br />CITY r7,U C �/ O�(/ � I <br />' <br />ACCEPTED BY: <br />STATE �q ZIP q 5-2— Y <br />l I <br />PHONE #1 <br />(z,, ?33 iso <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT <br />( ) <br />EM PLOYEEM <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQ UESTOR <br />REQUESTOR l.i <br />C TT �M �OE t� CHECK if BILLING ADDRESS LCL <br />I / <br />BUSINESS NAME r" �� <br />S/7��K%au S It�a*fl>FR) uL <br />PHONE# ExT, <br />X33 <br />HOME Or MAILING ADDRESS 2 /�, ,' ^ I� a -T r L <br />O ) J f � O i'V U fs � �.�1 L r <br />FA%# <br />( ) <br />q <br />CITY C iXn.N STATE Lel zip $Z )L <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, STATE and FEDERAL laws. J <br />APPLICANT'S SIGNATURE: V — — / r_ — DATE: <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT Is not the BILLING PARTY proof Of authorization to Sign is required Titre <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 a5 Soon as it IS available and at the same time It IS provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED; <br />COMMENTS: <br />MAR 0 4 2016 <br />SAN JOAOUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />/L� 1`, <br />ASSIGNED TO: - <br />EM PLOYEEM <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: + <br />PIE: <br />l <br />Fee Amount: <br />Amount Paid <br />3C), O (� <br />Payment Date 3 <br />Payment Type G �C <br />Invoice # <br />Check # <br />Received By: <br />U <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />