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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> ,hfon p rg - -2- � t 1915 <br /> OWNER/OPERATOR _ <br /> 1 amJ' LL CHECK If BILLING ADDRESS <br /> FACILITY NAMEPh CV,6✓ F Y _ f A I3-7 ' <br /> SITE ADDRESS POC'-�i /�/Dvt I O Street Number Direction l� li tSttreetCNamev l• lsbck-yp <br /> "I ZI Code 1 <br /> HOME or MAILING ADDRESS (If Different from Site Address)D51 Ra�/� 1 C/1 t I t Y y1 1�(t <br /> Street Number Street Name <br /> CITY I STATE ZIP r <br /> PHONE#1 EXT APN# LAND USE APPLICATION# '`xn <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1/1 <br /> The KoY cmB — \ I ,/1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME v -wr3J�I Psis L .Oa-1Li A i61 <br /> HOME Or MAILING AD ESS ^ , ,� (AX# ) <br /> t vt11 A <br /> CITY T n STATE Tl 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA d F�DERAL laws. Q� <br /> APPLICANT'S SIGNATURE: DATE: 1 I V <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ V 1 CC �C. \ 1 1 1 <br /> If APPLICANT is not the BILLING PARTI',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 <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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYP LIESTED: 1 rn � l (0if re to 1 1 1 ns — <br /> CO dEIVED SQ eU Gl I -F066 . <br /> OCT 04 2018 aporok Cate - d (fM-hOn I Ic6 - 1a 31 , <br /> �NtV�IRONIMENTALTM <br /> EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: i — 7 r_ <br /> Date Service Completed (if already completed): SERVICE CODE: 047 / P/E: 16,02- <br /> Fee <br /> 6,02- <br /> Fee Amount: 4P C)Z p0 Amount Paid �s-� v v Payment Date <br /> Payment Type Invoice# Check# 1076- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 0�1� <br />