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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS -26119 �,.rf/ G9wlP � gJ33< <br /> Street Number Direction Street Name city ZiD Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 2-117Yt C'MP-4Cs <br /> Street Number I- Street Name <br /> CITY STATE A ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2tf ) y6S' -S'45 / 77-/00 - 0v' X4 /7oo 175-� <br /> PHONE R Ezr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mid <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEt' PHONE# En. <br /> �rl /1?(/N/ udn 6/r <br /> HOME Or MAILING ADDRESS (] O'er FA%# <br /> I. rJ ( ) ;TY-0773 <br /> CITY STATE 6-4 ZIP 9f Zf <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 <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 FE aws <br /> APPLICANT'S SIGNATURE: DATE: /-7 <br /> PROPERTY/BUSINESS OWNER❑ BATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is n6t 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: OII iNifibliam ( (hdA ille"Ali RECEIVED <br /> COMMENTS: /_ <br /> 1z`as//y ,Qe„rwa NOV 2 7 2017 <br /> IV4'YI� ` SAN ENVIRONMENTAL COUNTY <br /> / rv"''✓� ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Hqtfa a EMPLOYEE#: DATE: 11 (2,,l II <br /> ASSIGNED TO: X'M l EMPLOYEE#: DATE: Z7 111 <br /> Data Service Completed (If already Completed: SERVICE CODE: 96 52,3 P 1E: Z(,QOl <br /> Fee Amount: 307. Amount Paid DCf _ Payment Date I R 7 <br /> Payment Type Cr Invoice# Check# 1�"' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />