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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,JIV+tip s� C 5'�Oos&- S <br /> OWNER/OPERATOR �Yf�/�A ' I <br /> / v(j�I N C-1 zN CHECK if BILLING ADDRESS <br /> FACILITY NAME / v"• 1 '+`t I <br /> POKE SA L4�P <br /> SITE ADDRESS2' � /�/M /�T? I 7/JGJ� 11�I Zd7 <br /> Street Number Direction /'t (r'l I�Street Name l vCI (\ /y Zi Code 1 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> U l: A Street Number Street Name <br /> CITY �^ --.. � � $TATE2ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (20 ) 244— <br /> PHONE#2EXT. BIDS DISTRICT LOCATION CODE <br /> 6 u - 7bo <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEill `� 1 PHONE# EXT. <br /> PC) 2-0' Z — 2 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY l STATE ZIP U <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: per;Y<I Z1n� DATE: <br /> PROPERTY/BUSINESS OWNER 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. <br /> TYPE OF SERVICE REQUESTED: zf&d <br /> COMMENTS: <br /> A 1 2019 <br /> ow SAN*JOAQuIN <br /> EftgRONM COUTy <br /> HFALTH DEpgENZA N <br /> ACCEPTED BY: EMPLOYEE#: �j � DATE: / t7 <br /> ASSIGNED TO: P <br /> EMPLOYEE#: 21vv� DATE: /� <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 1 lfio� <br /> Fee Amount: 5� (� Amount Paid Payment Date L4 <br /> Payment Type jr<:A' Invoice# Check# Received B � <br /> V <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />