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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property rFP"ILITY ID# SERVICE REQUEST# <br /> F t,� 6�fi S GI`�00 ll Ul��7Lt)o V <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �/ C <br /> ITE ADDRESS �C)Jlr) A�/L� ✓, Y-�J� f ov C- <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR rfGy� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME90�f t PHONE# p E.T. <br /> d7 h 1'`1 J J J(JL�> ZCfi t 3� <br /> HOME((NAILING ADDRESS � — FAX# )�5 (— ©� I <br /> LV'1 r-11�� S� <br /> CITYC-Ac--Tor 1 STATE ^ ZIP r"'� <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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ 1 P <br /> OPERATOR/MANAGER OTHER AUTHORIZED AGENT ��" Z -C'-F-0,y/ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirle <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�A 1 Or <br /> my representative. �' /"'\i NIM <br /> TYPE OF SERVICE REQUESTED: C��S C (,'Y1S\-A }v1 <br /> d I t -h on <br /> ECEIVED <br /> COMMENTS: i 2 2019 <br /> C5 <br /> SAN JOAQUIN COUNTY <br /> V�O C5 2ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ftl\,r EMPLOYEE#: DATE: 3 1-,Z`1Ll <br /> ASSIGNED TO: }-� EMPLOYEE#: DATE: 3'ZZ, 161 <br /> Date Service Completed (if already completed): 3�22/�G1 SERVICE CODE: Cj P/E: D 2 <br /> Fee Amount: D� Amount Paid Payment Date � aLZ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />