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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gpgce� rto.P SA bo 78?57/ <br /> OWNER/ O ..gy�pp Lyr�,I.Its,, c.�/�,� <br /> /( d/ c CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEA�DDDRESS s CARR o�-ro �D. >z(I&t l a53�6 <br /> 2"6' Z 5StreetNumber I Direction Street Name CIN Zip Cod. <br /> V <br /> HOME Or MAILING ADDRESS (IF Different from Site Address) LL,, <br /> ' FpT'C�- CT- <br /> 2- J CQ r/b�l r�✓/ <br /> Street Number S[reet Name <br /> CITY g.IPo1\L I STATEGA Zip -36/- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# Y/ <br /> ( ZM 60 z - -7oSoL�{Sa�CC� i P -1�2001JO <br /> PHONE#2n/,6 EXT. BOS DISTRIC LOCATION OOE <br /> ( ) Zm <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR VW LI-\tJl1 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 11.4 VG I. I! PHONE# n '/21 J EXT, <br /> 1. IW. Gj �Q ��l J <br /> HOME or MAILING ADDRESS 11(-7 L sZ>E6T FA��x'#J R3 Z -'763 <br /> 3 <br /> (7TTt0) <br /> CITY Hov6,/�v STATE /eZIP q,53g 4� <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 preparedthis )31rtipation a d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TAr and;p AL laws. <br /> APPLICANT'S SIGNATURE: (/ DATE: I� <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <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 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. <br /> TYPE OF SERVICE REQUESTED: MEN I <br /> COMMENTS: F-evieA loC`)It- �jol-N"S -I Tl< 'f;;TuVy <br /> I�,Y/�[� /tem, a}„� t,c� ry✓•�4�� DEC 2 9 2017 <br /> SAN JOAQUINCOUNTY <br /> 69 ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: I <br /> Fee Amount: Amount Paid -3d �./ Payment Date <br /> Payment Type Invoice# Check# O S Received By: <br /> q,A EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />