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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business orPropert��ry FACILITY ID# SERVICE REQUEST# <br /> Re `� aw7" <br /> OWNER/OPERATOR <br /> '50 <br /> (' rV CHECK If BILLING ADDRES <br /> -ko <br /> FACILITY NAME o7 �y �i �. ' O {U <br /> LC. y� p X <br /> DJi <br /> SITE ADESS /y� L I /' r \ ^\/,, <br /> 2 GStreet Number Dlrecnon Str¢et Name �J J CI \ Zi Coae <br /> HO9 ME or MAILINGG�AADDRESS Different from Site Address) <br /> 2e, 1, GLrea.� C � Street Number Street Name <br /> CITY CA ll <br /> TAZIP " <br /> �fzs CEC'FO r � an <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# 3 <br /> edq) � <br /> « —� 2 � ��� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION�CODE <br /> ( ) 6 —d <br /> U — <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> [REQUESTOR Q f / InSSIso///����}- CK """/�^� CHECK If BILLING ADDRESSINESS NAME }ten I a t 'm t P # nME or MAILING ADDRESS 1 �+I•l l� / 7-A FAx#Y C\C STATrC//� ZIP <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-wiprk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and EDERAL laws. <br /> PLICANT'S SIGNATURE: <br /> DATE'ZI T — O- ZO <br /> PROPERTY/BUSINESS OWNER L7 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 /> 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: ` Oki PAYMENT <br /> COMMENTS: <br /> Gt 0,I o- Own e( JUL 10 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT, <br /> ACCEPTED BY: EMPLOYEE DATE: `7 l0- ! O <br /> ASSIGNED TO: In EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P60 IE: --;1— <br /> Fee Amount: 1 — Amount PaidI Ij`a Payment Date 7 o <br /> Payment Type C Invoice# Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />