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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ffCHECFCirBILLINGAUC- =5 <br /> FACILITY NA—ME•\� \^) <br /> SITE ADDRESS 5 e� � <br /> �_— �t� Street Number Oirnaction St t'. City it,go 1 <br /> I NOMI Or MAI:'u .._DRESS !.i'!: erent tram Site Address) - <br /> ;,� C) ,jEE0x 169 <br /> Streei Number _Street Namc _ <br /> :Y ANSTATE ZIP <br /> P[WNE#1 EXT' L 1:'N# LD USE Ai'i _CATION'' <br /> ,'&T 239_ 44 _ I <br /> PHONE#2 E,r, BO'L DISTRICT —' Lcr c _ON C;)DE—� <br /> _ <br /> CONT"_("TOR i SERN71CF, RE,Q ESTOR <br /> REQUESTO e, �W� I r <br /> LL CHECK It BILLING ADDRESS�- <br /> BUSINESS NAME PHONE# NEXT. <br /> (_M) <br /> HOME or MAIL.;JG ADDRESS FAX# <br /> CITY `� r STAT ZIP <br /> BILLING ACKNO'WLEDGEM,ENT: 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 applicationAnd that the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> :BOUNTY Ordinance Codes, Standards, STATE andYZ E AL w . <br /> APPLiCANTIS SIGNATURE: <br /> DATE:— <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E3_ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required rir[e <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 COUNT) ENVIRONMENTAL HEALTH DEPARTMENT aS soon as it is available and at the same time It is provided to me or <br /> my representative. <br /> I T VDr nMENT <br /> r Cr!nmr urr.iircTrn• sl <br /> COMMENTS: REeEl WED <br /> JUL 2 7 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: CLA LQ -MPLOYEE tt: Y DATE. Z&7/A., <br /> ASSIGNED TO: (� 4�.�J_' !NP'_OY=E#: DATE: '71Z--7 <br /> .ie Service Campy feted(if[' a!ready'Cc'om::leted): F aCECooE_ S2'1J P1E: 1+ <br /> rce Amount: �p Od Amount Paid O i'a� n ^' Date �7 /� <br /> _ . <br /> Payment Type Invoice# Check# l S S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> E <br />