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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUTYID# SERVICE REQUEST# <br /> 500 <br /> OWNER/OP TO <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE A(DDRESS 1r — L �� j� L�7/(� '"'� <br /> 1 o S I `atreet Number Dlrectlon 'P�l.�1 slf¢w Z 1 J <br /> HO E r MAILIN �ADDRE55 (If Different from Site Pddress) ( � r/� <br /> Street Number Nam <br /> CITY .(�� STATE Z <br /> PHONE11 Y APN# 0 LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION C(OlDE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST �^ <br /> l� CHECK If BILLING AODRES <br /> BUSINESS NAME P Ems' <br /> HO AILING ADDRESSc—, Cc a I t� 2 A FAX# lJ I <br /> CITY o STATE zip �j O <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 /> 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,Standard TATE and FEDELl 11 1 <br /> APPLICANT'S SIGNATURE: R ws. AcDATE: <br /> PROPERTY/BUSINESS OWNER 13 4AT10 <br /> ANAGER OTHER AUTHORIZED AGENT ❑ <br /> IfAPPucANr is not the proof o u orizatfon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFWhen appli le, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the rend all results,geotechnical data and/or environmental/site assessment information <br /> t0 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: <br /> COMMENTS: yC+I�LiiD <br /> MAY 14 2018 <br /> /V �QUIN <br /> MONMOUN <br /> N <br /> / V COUNTY <br /> ACCEPTED BY: EMPLOYEE M BNT DATE: <br /> ASSIGNED TO: C+ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 43 <br /> D Amount Pat �� ,0D Payment Date / <br /> Payment Type C Invoice# Check# 1 Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />