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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�DY Fw22-(1,LW s rooso�'uS <br /> WNER/OPERATOR <br /> VI' � � 1 �/ly� CHECK if BILLING ADDRESS <br /> FACILITY N E r �/I <br /> 1, <br /> SITE ADDRESS t(fl <br /> �a-o- 1�1S i' ridge �1az�i Ty�tpnfiStreet Number tion I Street Namecity Tr Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) p�oufi C I�p N DYE <br /> Street Number Street Name <br /> CI zipUy- <br /> STAT li (3 501 l� <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (109 ) %25- bDbq <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( (O09 ) �6'l Too 71 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> In Y) f CHECK if BILLING ADDRESS <br /> 611 <br /> BUSINESS NAME i I PHONE# ExT. <br /> C at rc ( bog 6ql -1001) <br /> HOME Or MAILING ADORES <br /> I Ob 901 A vt 00 �Uri 1n (601 .) <br /> 5 •! b 7 <br /> CITY V VI TY I STATE N-5 ZIP 0 bo <br /> BILLING AC OWLEDGEMENT: 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 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE:N—�A Aa.,. o DATE: C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �N x U IVS'r <br /> If APPLICANT 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 environmental/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: d <br /> COMMENTS: <br /> MAY 2 8 2019 <br /> SAN NVIRQUIN COUNTY <br /> HEALTH DEPARTME <br /> NT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ��j, PI E: (P®� <br /> Fee Amount: �14 ;)--a) Amount Paid lea , DO Payment Date 51Z8'f17 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 W l t / �(y J� ( Z SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br /> ��� Ltt�63 3 <br />