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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2- <br /> OWNER I OPERATOR <br /> Oa2nr+/w^�/1��w Wa��aM CHECK If BILLING ADDRESS <br /> FACILITY NAME V <br /> SITE ADDRESS 19099r l9 23 A.tslitr.75.i 90.4D GGt£M ENTJ gl'ZZ7 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIT( STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (" ) I 623—e;," - 06' ' Z9 M- /b- <br /> PHONE#2 Ez. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR MIKE Tn <br /> CHECK If BILLING �Ek <br /> BUSINESS NAMEEXT. <br /> A/Ltov d /t.fv�#y PHONE III 33 ¢-6b/3 <br /> HOME Or MAILING ADDRESS to. 0. <br /> O pox 2-1 ,90 FAX# D�y <br /> U ( an ) �3�-- 3 <br /> CITY LDO STATE ZIP 9$7A <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,STA/TEaws. <br /> APPLICANT'S SIGNATUKI6% DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IjAPPLICANT 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 <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; �LX/IjPaCg, J1A- SWI Lc L) <br /> COMMENTS: RE V�yEN�' <br /> e�/ a/ � sw v SW6^r4 MAY <br /> 90 r J <br /> 3 2016 N <br /> /YSAN,, <br /> IY <br /> ACCEPTED BY: EMPLOYEE#: W- 1ASSIGNED TO: EMPLOYEE#:Date Service Completed (If already completed): SERVICE CODE:Fee Amount: Amount Pai (.d Payment DatePayment Type Invoice# Check# 1 3 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />