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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t e <br /> OWNER i OPERATOR <br /> `n CHECK If BILLING ADDRESS <br /> FACILITY NAME FE 5 v <br /> SITE ADDRESS �54 'tk51F�' S 2 LIDO—, <br /> 9 240 .. <br /> 1 lJ Street Number Direction ree CI _/�ZI Co—tler <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#7 E%T. APN# LAND USE APPLICATION# <br /> (20q) 323 !E3 NoO-YW'�S <br /> PHONE#2 E%T. BOS DISTRICT LOCATION DE <br /> ( > o O� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING AODRESSO <br /> BUSINESS NAMEj� PHONE# Exi. <br /> V 2 42S 3 (0 <br /> HOME Or MAILING ADORE S FAX# <br /> CITY STATE /may ZIP qj S. <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,STAT and FEDERAL'J'A,s. <br /> APPLICANT'S SIGNATURE: DATE: .� 112 ) 1 <br /> PROPERTY/BUSINESS OWNER❑ PE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the G PARTY proof of authorization to sign is required T'iele <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 /> t0 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. PrkYNIENT <br /> TYPE OF SERVICE REQUESTED: �-� �( <br /> REGEIVED <br /> COMMENTS: <br /> GYZa✓lc�e- v� �vJn erslu P MAR 0 2 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C .,.1 EMPLOYEE DATE: •^1. <br /> ASSIGNED TO; aJJ�KII�� eZ_ EMPLOYEE#: DATE: c-/ _Z_/OS( <br /> Date Service Completed (if already completed): SERVICECODE: C, r I PIE: <br /> Fee Amount: �iY> Amount Paid Payment Date 2 1 <br /> Payment Type�,,�� Invoice# Check# l�Gl Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/77/08 <br />