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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a;1 _ Gr0Ceyy SS0owII <br /> OWNER/OPERATOR ^/� /� <br /> /r 1 i-D A 1 IL- Srt L� O I� CHECK If BILLING ADDRESS <br /> n� <br /> FACILITY NAME <br /> MII1gGEO ;?3iL- SALCnn 0M�A(� _ r oar �- <br /> %O` / <br /> SITE ADDRESS �"7 S Sir` 3,1Rc,ur"I St- Z7AC' ''40- C(SZo6 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> l'Y S 2 Y Street Number Street Name <br /> CITY STATE ZIP <br /> �eC V-\UVB C_0 q5 �2 1 Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (;aO� `X9 - S S 20 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> M AGL-o 'vRg,L SAi_E►vl G w CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> �Ue .}car <br /> HOME or Or MAILING ADDRESS FAX# <br /> SS21keYSe,- 13Y ( ) <br /> CITY S-kcc kAC�� STATE ZIP QS <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/BUSINESS OWNER❑ PERATOR/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 It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENI <br /> COMMENTS: RECEIVED <br /> NOV 2 6 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I✓`1 Vl r (� EMPLOYEE#: ✓✓✓�b DATE: I �� / <br /> ASSIGNED T0: e ma (/� V l v EMPLOYEE#: wDATE: 1112-611r <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I (//12 <br /> Fee Amount: G,�.UGI Amount Paid s��, Payment Date l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />