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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE QUEST-# <br /> OWNER/OPERATOR//�(� <br /> / //•(L Vin CHECK If BILLING ADDRESS <br /> FACILITY NAME l/ V LGG <br /> SITE ADDRESSJ� AVC• 5"� Gle 7 SZ/5 <br /> Street Number Direction Street Na a • / C' ZipCode <br /> HOME or <br /> Z MAZILIN'ZG7ADDREmSa As <br /> Slreat Number Street Nam. <br /> CIN �G (j�', STATEL�� ZIP 7'5 ZO / <br /> PHONE V EXT, APN# LAND USE APPLICATION# <br /> (zoo) 4�0 - IC) <br /> /57 Z4- - is <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 11 C) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jdli CHECK If BILLING ADDRESS <br /> BUSINESS NAME lLii IDILLVN h PHONE# (o&13ExT. <br /> HOME or MAILING DRESS Ftx# <br /> 0 o/ o ( ) 34 -3 <br /> Cm ') STATE /'4 ZIP G`L4/ <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 UORATOR/MANAGER ❑ OTHER AUTHORIZED AGENT/f APPLICANT is not fUNG 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: <br /> COMMENTS:i2lir-- p// RECEIVED <br /> OCT 18 2017 <br /> SANENVIRONMENTAL <br /> EJOAQUIN TM <br /> ACCEPTED BY: Ufa EMPLOYEE HEALTH DE <br /> ASSIGNEDTO: EMPLOYEE DATE: D / <br /> Date Service Completed (N alrem <br /> ady copleted): SERVICE CODE: GJ-�-� PIE: <br /> Fee Amount: Amount Paid d — Payment Date 1 f <br /> Payment Type Invoice# Check# Ur Received By:7' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />