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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR I WENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRa°7y 88 � <br /> OWNER/OPERATOR <br /> -�3 , r�C�y' ll - -_--- CHECK If BILLINGADDRES _ <br /> FACILITY NAME V W vS Fl �--(�J2 <br /> 257- <br /> SITE ADDRESS / / /� 5 6 <br /> Street Number Direction �ij ��1��/S,eet Name D ca CilyZi Corte <br /> HUMS Or MAILING ADDRESS If Different from Site Address) 1 s 6 77 <br /> !1 2X4(1-- 5- wNl1NGY un ROLNLIti Slree[Number Street Name <br /> CiTY STATE ZIP <br /> AM <br /> PHONE Mt EXT. APN# LAND USE APPLICATION# <br /> PEON(# fj0 Z -017 `/ --- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTPUA CI'OR It SERVICE REQ TESTOR <br /> REQUESTOR <br /> Rc CHECK If BILLING ADORE55 <br /> �BUSINESS NAME O PHD�# 02 D Ext,Il <br /> HOME or MAILING ADDRESS r lG b�U� FAX# <br /> CITY amP� STATE/ ZIP D SZ <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. <br /> APPLICANT'S SIGNATURE: JIn,}�(I✓Gr 60'L' DATE: 5-17-16 <br /> PROPERTY/BUSINESS OWNER 11 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me Or <br /> my representative. 1. <br /> TYPE OF SERVICE REQUESTED: R�MA ve't c�& <br /> COMMENTS: <br /> MAY � � V <br /> sgN�oq ?016 <br /> HfAcry'oo qA j L Nry <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /1 EM 'LOYFE#: DATE: ✓' 11 I� <br /> Date Service Completed (if alreA4 complete . S'.:RVICE CODE: CI P1E: 1 03 <br /> Fee Amount: ,6j Amount Pald> f DL/) Payment Date <br /> Payment Type [ _invoice# Check# Received By:aA,,)— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />