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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7C/�D� <br /> OWNER/OPERATOR _ <br /> L-J(\4"' / \- � ��/� CSC, <br /> FACILITY NAME t� , CHECK If BILLING ADDRESS <br /> r`1�1� 1� <br /> SITE ADDRESS U Y A Z 0 N\ckykQ � c l S-z,�6 <br /> �et NE umber Direction \\ r Strreet Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> \\\,-- N a .,A st• �N r-)3.0-� N . ���,Y\ <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> � ��c� C A � X336 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (s"t9) � �o - y 1 3 zz — 0 3,0 fit PR— I S0 0111 <br /> PHONE#2 _ EXT. BOS DISTRICT LOCATION CODE <br /> (201 6 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ '--S' / V ' C'1 \` CHECK if BILLING ADDRESS <br /> BUSINESS NAME �M n �7 1 PHONE# Ext. <br /> -2S (J <br /> v — k 5 <br /> HOME or MAILING ADDRESS FAX# <br /> CITYSTATE ZIP Ov::-:;� <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 prepared this application_ and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S ASE and �eorRAL la <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY I BUSINESS OWNER 19 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: OW MENT <br /> COMMENTS: RECEIVED <br /> AUG 15 2018 <br /> 42 SAN JOAQUIN COUNTY <br /> l E111RONMENTAL <br /> ACCEPTED BY , � EMPLO DATE: <br /> ASSIGNED TO: .'vI I �Jf EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 47-, P I E:�(�,v� <br /> Fee Amount: i f�1C.-�'v Amount Paid Payment Date <2 I s 1 g <br /> Payment Type O Invoice# Check# CDs 5& Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />