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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O�GrUDoo I-i-G(a sko0- -F38 cao <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FA LITY NAME \ ME�V MnIF- <br /> SITE ADDRESS ©�/ t FIc Q v � T90�• <br /> Street Number Direction T r v� Street Name CI Zly Code ' <br /> HOME or MAILING ADDRESS (If Different fro Site Address) <br /> �a RZ*rStreet Number Street Name <br /> Cl rr� � STATZIP <br /> n � <br /> AP(H�UN #1 ExT. APN# LAND USE APPLICATION# <br /> 1` Ig I— q � Il <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ('20) g— 0t8 9 00 2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , <br /> CHECK If BILLING ADDRE5511 <br /> BUSINESS NAME f' PHONE ��� ExT. <br /> yl 1:11 tA �y 4 r <br /> HOME or MAILING DDRESS V �A^ -� FAX# <br /> CIN STATE is <br /> (jJk ZIP ry <br /> BILLING AC NOrWLEDGEMENT: 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 /> 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 FED <br /> APPLICANT'S SIGNATURE DATE: -;;W 13, 2019 <br /> PROPERTY 1 BUSINESS OWNER V OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> !f APPLICANT is not the BLLIN�PARDv 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the sar Qui �grp I ed to me or <br /> my representative. /��+il��l �� J� <br /> TYPE OF SERVICE REQUESTED; (��� C`G 5 L� j i�� 0 Z �E�� <br /> COMMENTS: �ew � MAR 13 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �n„ EMPLOYEE M DATE: ' r IF <br /> ASSIGNED To: dh rscr)L,-t-- EMPLOYEE M DATE: f (3 W <br /> Date Service Completed (if already completed): SERVICE CODE: aa{ P!E: I b bZ <br /> Fee Amount: $ I vv Amount Paid �S� ts� Payment Date 13 I I <br /> Payment Type (I Invoice# Check# 1 tx}-1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />