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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> kFA <br /> Business or Property FACILITY ID I <br /> SERVICE REpUEST M <br /> S 10�ro c ivI OPERATOR ~ �.�i��^C(-/T� �. 1ASQ. L� LCHECK If BILLING ADDRE SO <br /> AME $IN�L� FAp4iL $IR� D�r�(�REss S�qEN H / �j[f1[,�0.4 K �Q r✓E 6.r1 o C- -ronl g 5 ?i 2.,,,. c d• <br /> MAILING ADDRESS IIf Different from Site Address) � Ot. Nn <br /> /1Ar)A CA <br /> STATE5Tef-rG-r©rJ ZP C'p. 5 x,12 <br /> APNLANO USE APPLICATION 0 <br /> 323 - 3 0 VU"— <br /> REDUESTOR CONTRACTOR/SERVICE REQUESTOR <br /> ,J 8 t R C.%4 ESE M A COW=B <br /> BttinuEs6NAME ELITE L="0a-r2 p4ora Ea*. <br /> 2• 3Z3 - -733Li <br /> HOME or mmumo ADDREes fAX a <br /> �3 E lN1°f nq LALs e I <br /> Crtv 5T0'`k—TOA STATE jtp <br /> CA 9 52f 2 <br /> BD..LING AC"OWLRnr_EMRNT: 1, 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,Srandar TATE and FF L laws. , /' Q� <br /> APPLICANT'S SIGNATURE:_ �f/�t./ Y DATE: I— Q— r 7 <br /> PROPERTY/BualNzss OwNEt O RATOa/MAN ER ❑ OTHER AUrHORrccD AGIM❑ <br /> If APPLICANT is not the BILLtA'O PARTY ProOf of authorization Jo sign Is required T/r!e <br /> AUTHORIZATION TO RE Fa,g 1NFORASATION: When applicable, 1,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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DENT as soon as it is available and at the same time it is <br /> provided to me or my representative. MENT <br /> TYPE OF SERVICE REGUEsTEO: iVED <br /> COMMENTS: G <br /> N/ 7 i Fit 5 7 „P y JAN 10 2019 ;AN 0 9 2039 <br /> SANJOAQUIN <br /> ENVIRONMENTAL ENVIRONMENTAL HEALTH <br /> HEALTH DEPARTMENT PERMIT/SERVICES <br /> ACCEPTED BY: EMPLOYEE M: <br /> BATE. 1 d ZD <br /> AsatDNt 0 TO: zj�/ nM EMPLOYEE#: BATE: I /I C) 2 0 9 <br /> Date Service Completed (N atnady eom ►: L� r l sERnCE CODE 523 PIE Z J <br /> Fee Amount• Amount Pal 3 . Payment Date b <br /> Payment TYPa Introiea i Check# JJ Zd Race lly: <br /> EHD 48-02-M <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />