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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> GE inloorto <br /> OWNER / OPERATOR n LI C n CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Cwd -c r <br /> SITE ADDRESS �� 33 14 — tc'b i' " 01 V"Fe <br /> Street Number Direction Street Name City ZID Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) A IWZ <br /> 4 orStreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # 01 <br /> ( meq ) q43 32I 3 C23"32at) ( SANJOAQJ/ <br /> PHONE #2 EXT. BOS DISTRICT tAjxJ rAL <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORV I jp � <br /> L '\ CHECK If BILLING ADDRESS <br /> EXT. <br /> BUSINESS NAME [3�tI � P f,+ ,_ I C �1 PHONE # ��Z _ ` �, � /0 8' <br /> HOME or MAILING ADDRESS f YU l�� �( <br /> °l� � vq cAye c <br /> Ay �ooa X4- 2 - 0131 <br /> CITY IV I O / f7jS STATE ��3SZIP <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 F DERAL laws . 2 <br /> APPLICANT' S SIGNATURE : lcall))L� DATE : / f � <br /> ! 11 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / 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 /> to 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 . II in l <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: <br /> RECEI E <br /> MAR 0 4 2019 <br /> ACCEPTED BY: EMPLOYEE q ENVIRk RR1EdTAVd1'mt ITt-I <br /> ASSIGNED TO : EMPLOYEE M ( ( ) Nt%R �� ICV <br /> Date Service Completed ( if already completed) : SERVICE CODE : q PIE : J3 0,S <br /> It <br /> Fee Amount : 41, Amount Pai L�s� D� Payment Date S / <br /> Payment Type Invoice # Check # � l o� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />