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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Jwj' FPtGk)24gc05 <br /> OWNER/OPERATOR <br /> MACHECK If BILLING ADDRESS PA-0, CMCL <br /> / <br /> FACILITY NAME tAe,V; SSO bCA.A C6 LO <br /> SITE ADDRESS <br /> � _ PQ�rLmG� �� SfivL��?Z`T1 q�2 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /e _ CHECK If BILLING ADDRESS <br /> BUSINESS NAME C� p1 PHONE# EXT. <br /> V <br /> HOME or MAILING ADDRESS FAX# <br /> &0A <br /> 1 ( ) <br /> CITY ( S ZIP <br /> BILLING ACKNOWLEDG MENT: 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, STAT nd FEDERRA`�L/�laws.�,( �/J,�/f <br /> APPLICANT'S SIGNATURE: t fv`' (/VC/V6 DATE: <br /> PROPERTY/BUSINESS OWNER❑ AT /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 to me or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> 4 3gU5 DEC 04 2018 <br /> SAN <br /> ENVJOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: n EMPLOYEE#: DATE: ,Z/j-%`� <br /> ASSIGNED TO: 11� EMPLOYEE#: DATE: 2/ 'co <br /> Date Service Completed (if already completed): SERVICE CODE: U� 1 P/E: ,Cf U 2 <br /> Fee Amoun I�J� a Amount Paid !S a Payment Date /Z <br /> Payment Type LS Invoice# ch"' Zz, i'j — Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />