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Page 2 o <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUTY ID# SERVICE REQUEST# <br /> -T'F—N#MNT I m PFA VEMF►Jr OF 6 XIStINC4 f e ` �n J-� (P <br /> CH I I.D N'S N Ooolz P� Rw D - 1� <br /> OWNER/OPERATOR <br /> RtiD M0�WM1N G►�OVP 1 N(- . 11061 5 114k S%. Sp'OM PRNA �"B"""°AoDREEE <br /> FACIUTY NAME L Ij Y 2 p LA-1 <br /> SITE ADDRESS ' 1 A VA M S IL , /A tA 9 q S•L(Z <br /> 0 StrrtNumber r{M �T <br /> NOME Or MAILING ADDRESS (If Different from Site Address) <br /> S e t57 pta Strrt Number Strw Many <br /> CITY STATE ZJP <br /> PHONE 911 Fx'r• APN# LAND USE APPLICATION 0 <br /> I I A '4 b0 - 1500 130 - 02.0 - 10 <br /> PHONE 02 SOS DISTRCT LCATION CODE <br /> 1 14) b b - IS �, <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES OR <br /> L.-N Pkwr)r-4i CHECK H BILLING ADDRESS <br /> BUSINEsq NAME PHONE Err' <br /> _NP <br /> HohW or MAILING ADDRESS FAx I <br /> ( ) <br /> CRY pr�-v i P, STATE LP <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. w Q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER IfOTHER AUTHORIZED AGF-NT)K A?Zti <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 environmentaUsite 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. PA <br /> TYPE OF SERVICE REQUESTED: v l Ct jeC� <br /> COMMEM: <br /> t' CM t Z {� l c�✓t S SEP 2 5 2018 <br /> SAN NVIRON OU10Y <br /> NE4l7-!I pEAR7-Met T <br /> ACCEPTED BY: EMPLOYEE : DATE: <br /> ASSIGNED TO: (/LA EMPLOYEE il: DATE: _ Z <br /> Date Service Completed IN already completed): SERW-E CODE: PIE <br /> Fee Amount: Gj� — Amount Paid �s� D(� Payment Date <br /> Payment Type C' • C Invoice# 7 / Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17I2003 n� n�.l' /rte <br /> out:blank T 1�'v !�•�J 2, 9/24/20 <br />