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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business o7pperty L FACILITY ID# SERVICE REQUEST# <br /> eS r 1) l F�601-790'7 Dig -7 C/ � <br /> OWNER/OPERATOR. �r <br /> �Y ld A _ \eirr CHECK if BILLING ADDRESS <br /> FACILITY NAME 1 9L ( -s _ cIn <br /> ` a rVTI q Cl <br /> SITE ADDRESS �� / C c / yy� rOP '�,$3 3,v, <br /> StreeYl NhJmb'er Direeaon Fy Street NameCI 1 Zip Cod <br /> HOME Or MAILP'^A—rqs tlf n arert1t from S"a Address) p <br /> Z v^ "'0 V � C. Street Number i•'S�tFCA <br /> reet <br /> CITY 1 STATE ZIP T <br /> PH NE#1 EAT• 7u # LAND USE APPLICATION# U <br /> f�04) )$c)101 <br /> PHONE#2 ETT. BOB DISTRICT LOCATION C DE <br /> ( ) d <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CA�p rl L CHECK If BILLING ADDRESS <br /> BUSINESS NAME t t�l1 'y , PHONE# 'e2.6� <br /> 1. <br /> H 0 M E or MAILING ADDRES lA FA%# `� <br /> ou ase I i <br /> CITY STATE ZIP 33 Q <br /> BILLING ACKNOWLEDG MENT: 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 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 laws. <br /> APPLICANT'S SIGNATURE �JYC 0 •erre v'" DATE:_ R-9— I y/. <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUT ORIZED AGENT❑ P� -e.5/ den ) <br /> If APPLICANTisnottheBlLLlNGPARTr proofofauthorizatidn 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 t)Yane time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED/: 00C04 Sit/ Q2`1 1VE <br /> COMMENTS: Qn�e ©� /� . . \ n,e �•,S 1�• <br /> 1.1 lw 2018 <br /> VIF? 'IV COU <br /> lZU11OEpgR MIY <br /> NT <br /> ACCEPTED BY: \ ^,{ EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d W P I E: ' <br /> Fee Amount: 'S Z011Amount Pai Sz U-0 Payment Date <br /> Payment Type Invoice# Check# 61 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 /' <br />