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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3o -5 <br /> OWNER/OPERATOR _ <br /> C ,r 6 5� CHECK If BILLING ADDRESS <br /> FACILITY NAME P G KC y$,. <br /> sITE�7 �Jg. � �13TN�o� gS�3o <br /> Street Number Direction Street Name Cit ZiP Code <br /> Ho <br /> or AILING ADDRESS Bren/t from Si�ddress) <br /> LL I A/v[� Street Number Street Name <br /> CITY -y* I /C 9�f STATE 4 ZIP (J/S��S <br /> PHONE 1 EXT. APN# LAND USE APPLICATION# _I <br /> 00'7) GO - 693 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> OC1 ) 60? - 14993 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR L� l+ COS(O� 1 <br /> J p CHECK if BILLING ADDRESS <br /> BUSINESS NAME -p ,c K EV-5 tf UE r PHONE# Err. <br /> oq 0/61 -�Ig3 <br /> HOME or MAILING ADDRESS FAX# <br /> 19'y`q /ho G NE A�TECA cA - 9533 7 ( > <br /> CITY /� STATE C ZIP S33 7 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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, STAT and FEDERAL laws. LIgIc-9012 <br /> APPLICANT'S SIGNATURE: Q 'Q� DATE: // <br /> �f 4 <br /> PROPERTY/BUSINESS OWNER El/ 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 <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: E <br /> COMMENTS: ND v <br /> I v M SAN jo 12 2019 <br /> L�V tWI `"N oI�U�Ier J► IIp hEq`'THA0NMFNTgN� <br /> 0 DEP,gg7'46 T <br /> ACCEPTED BY: to r EMPLOYEE M �U�U DATE: I I 1q <br /> V UI/ v <br /> ASSIGNED TO: Q/I��� EMPLOYEE M q*r DATE: 11" <br /> Date Service Completed (if already completed): SERVICE'CODE: P E: <br /> Fee Amount: Amount Paid . a Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />