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JAN JOAQUIN UOUNTY ENVIRONMENTAL 11EALTH UEFAK7'MI1011 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 8ERII�E REQUEST <br /> r—r'a t'�etas �' CP (o 7 <br /> OWNER I OPERATOR <br /> CHECK N BILLe+a MOREss <br /> FACILITY NAME - <br /> T <br /> srr�EpAanREss f MARL44 L A NF- - 5Toatl-o 1V qct 7 <br /> sisal Number DNeeUon Street Nems I City Zip Code <br /> HoM Or ANA16 ADD SS (If Dlgerent from Sits Address) N <br /> __ S1netNumber r�/, (/l <br /> CITYt STATE IIP <br /> f i r GA 1463 If. <br /> PHONE 01 EXT* <br /> APN LAND UsE APPUCATioN# <br /> (107 ) T6 4. <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK O 9MJ.ING&EMS <br /> BUSINESS NAME iNrdftl PHONE 9 EXT' <br /> HOME Of AAAILINGADDRESS � `meq ) <br /> S RAL-, <br /> CrrY &, YPIP* <br /> STATE C A ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator <br /> q O <br /> 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 Flpl..O laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environnlental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: - '�7 cJIvL — _ RECC1+ D <br /> . <br /> COMMENTSNT : ��-------------- � r C <br /> APR 0 3 2019 <br /> SM JOAQUIM OU <br /> NEgL�p�NME � <br /> NT,q� <br /> EPgRTMEN <br /> ACCEPTED BY: f� t -- —-- EMPLOYEE#: DATE: _ 3 ,_ i <br /> ASSIGNED TO: C v - --- EMPLOYEE# DATE: Lt--3 —(9 <br /> Date Service Completed (if already completed): SERVICE CODE: 2_S PIE: ((CC) <br /> Fee Amount: 60 t `— Amount Paid 4 rJ/p, Payment Date <br /> Payment Type - invoice# Check# Received By: <br /> y <br /> EHD 48-02-0251 g 9 5?1P 9 I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />