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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> w\r(4PA," .iAL, L 1,s'mow)o� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FAcuTY NAME Z Nt J U 0 J`Qt v M' 'l v vr—t' <br /> SITE RESS i D Gl C- <br /> AM <br /> Street Number i an <br /> HOME or MAILING ADDRESS (if Different from Site address) <br /> St t umber <br /> CITY STATE TJP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PWME#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BiLuNG ADDRESS❑ <br /> BUSINESS NAME �j �iIZ`�it(ll� �'1 K�f V �U,011 fN L LL '�1/ ZLji( _ E4.106 Ezr. <br /> HOME or(MAILING ADDRESS FAx 411 ci l`S W?Y\� CIT <br /> ( ��t) <br /> CITY A VWW\J'V0 STATE 'x LP t,f5 <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 <br /> or activity will be billed to we or my business as identified on this form. <br /> I also certify that I have prepared ' applica on d a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan r STATE nd D w <br /> APPLICANT'S SIGNATURE: DATE: U ! 1 <br /> PROPERTY/BUSINESS OWNER❑ J PERATOR/MANAGER OTHER AUTHORIZED AGENT H <br /> If APPLICANT is not the BILIJNG PAItTF.proof o uthorization to sign is required Title <br /> A THORIZATTON TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENV[RoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. j� <br /> TYPE OF SERVICE REQUESTED:: 2. T` �' W CU <br /> CoYmem: Z- v� r v'ijl C / A I 9 2017 <br /> ���RC �tL �'t/�cvt OAQ <br /> ENMRONME COUNTY <br /> HATH DE EN <br /> ��/C T EMPLOYEE#: DATE: <br /> ACCEPTED BY: ( 7 Gam/ <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE' <br /> pgte Service Completed if already completed): <br /> SERVICE CODE: 7 Z (PIE:( -jZ <br /> Fee Amount: Amount Paid Payment Date g 911 <br /> Payment Type i SGS <br /> Invoice# Check III Received By <br /> T g <br /> 64e`1 3 ,, ,�/0 �`' R FORM(Golden Rod) <br /> EHD 4&02-025 C Y{ L W`✓ C `'�mck� (� <br /> REVISED 11/17/2003 <br />