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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> ICC' Cnat" GM pS ow\A snoc X14 ODD 123"-) _C; <br /> OWNER I OPERATOR /A1 <br /> �s Q,c !^ v Ck ru Jo CHECK If BILLING ADDRESS <br /> FACILITY NAME tel/ <br /> 1ce-- A Gre aft, I���� <br /> SITE ADDRESS 4435 'V1• ` Aelky\ 'S'T <br /> Street Number I Direction Street Name cityZi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) n 2 .LJ�,�/;h r71 n P <br /> � p <br /> L Strael Number 6 � t/L V t5treet Name °C <br /> Ct a1 d S ATE ZIP , `�/1 L4 <br /> HONE#1s�o� _ 12- Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` CHECK If BILLING ADDRESS <br /> Z5ct4c A lUG rcJo Vvu N-caa <br /> BUSINESS NAME PHONE# EXT. <br /> 'T Ce C rcat'ml aa ( 0. /0 ?OCI Ey/2 <br /> HOME or MAILING ADDRESS 2 1 <br /> /'2,p FAX# <br /> b <br /> CITY Up7. /` rQ./ STATE `A zip (' q`L/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 la`ws.' <br /> APPLICANT'S SIGNATURE: <br /> scS r G J1�f add DATE: 2 <br /> PROPERTY I BUSINESS OWNER Ltl OPERATOR I 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. P <br /> TYPE OF SERVICE REQUESTED: Z- �Y' I RECEI <br /> COMMENTS: FEB 15 2018 <br /> aAN JCL40UIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEM HENT <br /> ACCEPTED BY: f AAD EMPLOYEE#: DATE: <br /> ASSIGNED TO: I 1,- .�i- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 1 c�2 <br /> Fee Amount: q 15 2- Amount Paid I a, Payment Date a, I S / p� <br /> Payment Type Invoice Al Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 `/'� <br />