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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> been- � snq FA D61967 9 5R0b77L/ <br /> OWNER 1 OPERATpfR- <br /> W o0&Y i r4 /� o,r } L� CHECK If BILLING ADbRE55 <br /> FACILITY NAME W 0 uc y d -le_ 0(\co deA <br /> SITEADDRESSLowe, . Sae�o��menko � 1ori dg2 gSZ58 <br /> ! U i 11.� Street Number 1 Direction Street Name Cl Zip Code <br /> HOME or MAILING <br /> GA'DDRE S (if Different from Si^}7/e Address) <br /> f <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Pq) 'l.02 --�OD2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR i <br /> 00) CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT.L 0 Z02--7aD 2- <br /> HOME Or MAILING ADDRESS FAX# <br /> S- ' ifllcl t ) <br /> CITY STAT 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 /> 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 FRAL laws. <br /> APPLICANT'S SIGNATURE: ED DATE-... Jq 1-7 <br /> PROPERTY 1 BUSINESS OWNER❑ OPERATOR 1 MANAGER JQ Lr <br /> 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 /> to the SAN JOAQUIN COUNTY ENV:RONMENTAL HEALTH DEPARTMENT a5 soon as It i5 available and at the same time It IS �e!or <br /> my representative. vwf�T <br /> TYPE OF SERVICE REQUESTED: c E <br /> COMMENTS: MAY 0 9 2017 <br /> SAN JOAQUTAI COU <br /> HTMRONMEMAa M r <br /> ACCEPTED BY: EMPLOYEE#: DATE: 5 <br /> ASSIGNED TO: EMPLOYEE : DATE: �j� _11 <br /> Date Service Completed (if already completed): SERVICE;CODE: 1 PIE: ip b� <br /> Fee Amount: Amount Paid 139 D� Payment Date `7 n <br /> Payment Type ! (!J� invoice# Check# Received By: ally— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />