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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rA 001 -�slq<2 '�;42 0'0 <br /> OWNER/OPERATOR <br /> J - J CHECK If BILLING ADDRESS <br /> U Sp, C-N r21 <br /> FACILITY NAME <br /> SITE ADDRESS 1 I 1 � 1 r /1 - \ 1 01C3ZL40 <br /> Street Number Direction l f V ` Street Name T city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site dress) —L "C i-' ) <br /> Ji I-1 Str et Number <br /> � Street Name <br /> CITY 1/ $T!}TE -5 ZIP l <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2%7) -1.15 - '1 1;3 5 I <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> I BUSINESS NAME PH # EXT. <br /> +3 t,)e? 3S —7 �i't j --7'd I <br /> HOME or MAILING ADDRESS FAX# <br /> 1-1 -7 1 <br /> CITY �1—_' lL�� STATE/ ,_4_ ZIP '-1 --5-5. 9 J <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 FEDER <br /> APPLICANT'S SIGNATURE: DATE:�f 55 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTH HORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirie <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 to me Or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: l �' _ RECEIVED <br /> COMMENTS: <br /> MAY 15 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONM NTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: v�/1�1 lN;fi��n(1 ' lJ/ EMPLOYEE#: DATE: '5 �� I"el <br /> TO: ^ '� EMPLOYEE#: DATE: <br /> RA <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: I�J�L <br /> Fee Amount.tr l ' 2 f-- Amount Paid l Payment Date <br /> Payment Type �9. Invoice# Check# rj Received By: Y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />