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• `fii -nD <br /> SAN JOAQVCOUNTY ENVIRONMENTAL HEALTH DEPARTMENTOC �I <br /> SERVICE REQUEST per oLoner <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � . ( ems(. t�, . H637� 5 pe�lvl�a� <br /> OWNER/OPERATOR JJ�� t K/'� <br /> If_o f 1 S I "C CHECK If BILLING ADDRESS <br /> FACILITY NAME 7fe��/ 1 O L,V P C r! C V✓Z-a✓1 �1� c7 <br /> SITE ADDIR S I IC. � ���`� 13 LV0 I K,t4 LY 7 T.�OL� <br /> -3-7-7 Street Number Direction Street Name CI ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR1 <br /> L_ <br /> CI'V G(•_, Y✓L'(� C.-i /LJ A'A CHECK if BILLING ADDRESS <br /> BUSINESS NAMEF " P E C ��,/1 (31o) 8�Z �1 3 <br /> PHONE# E-. <br /> HOME or MAILING ADDRESS t( "'1 7, O v Y_, ,v w �I AIJCFA%# <br /> CITY `� (� STATE /' ZIP C3 Uz LZ <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, ST EDERAL la <br /> APPLICANT'S SIGNATURE: DATE: O I I 1 g L7 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT/yp-r (fO t77Z/l,7-C <br /> If APPLICANT is not the BILLING PARTY proof Of authorization f0 Sign Is reQU1rC0 Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 as It Is available and at the same time It Is provided to me Or <br /> my representative. ]� <br /> TYPE OF SERVICE REQUESTED: `1 PAYMENT <br /> COMMENTS: RECEIVED <br /> SAN 19 2017 <br /> ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: / - //.l <br /> ASSIGNED TO: 4415 M l 0 EMPLOYEE#: DATE: — _/`7 <br /> Date Service Completed (ff already completed): SERVICE CODE: 1A PIE: .256 C� <br /> Fee Amount: q/7-2 Amount Paid co d Payment Date <br /> Payment Type �. `� Invoice# 2'(r!qr5- Check# Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />