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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# AERVICE REQUEST# <br /> (�ra2.. iZ eS %0 t-t aLt�.ti� <br /> -FP'1 C 00009 S )(;0 <br /> OWNER/OPERATOR <br /> -� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> C'f) : " CrJk�, I c' /`1 -e <br /> SITE ADDRESS M W 1 <br /> Street Number Direction i,vv Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2 <br /> 915 L S P L P'V'/•ALJ I� C C,tit I U Street Number L ti 'L Street Name <br /> CITY STATE ZIP <br /> L)AA"" pv Ll�WG z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 21 ) 127 D OC� 1310OI <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) -I of <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 20 fZ/•e c .A L A--T r. � ,? CHECK If BILLING ADDRESS El <br /> Co <br /> BUSINESS NAM , ti%AY �/ e` PHONE# EXT. <br /> O <br /> HOME or MAILING ADDRESS FAX# <br /> /< - L AQq 10 I2 ( > <br /> CITY /) C A M n b STATE C Az ZIP IS'2 2 <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. 7� <br /> APPLICANT'S SIGNATURE: WJ DATE: 7— l dY <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tire <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 INT e or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: � COy-6W-IAb bv`, <br /> COMMENTS:C*t(4 q (9( �, � .„^ - S `I j J U L 19 2019 <br /> �`��yy�� IJ�J`/U(/I Vl/V SAN JOAQUIN COUN <br /> TN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 `1M EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0 PIE: ' 2 <br /> Fee Amount: ( 1�2 W Amount Paid — Payment Date / <br /> Payment Type Invoice# Check# _ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br /> Ila �gl d <br />