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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR SP cog A,—P,*" <br /> NGoC CHECK if BILLING ADDRESS <br /> FACILITY NAME S LU4y : ,�-/K&- <br /> SITE ADDRESS "ta-t— �'l 4 p _/ <br /> l�4a-- J <br /> Street Number Direction ✓ treet Name , Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number `( �'"' stet Name <br /> CITY Sf YL-r l- r n. A STATE ZIPQ <br /> PHONE#1 ✓ ' 1 EXT. APN# `�� LAND USE APPLICATION# ( rW- <br /> 7/I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> l 9&'tVI J �/ CHECK if BILLING ADDRESS <br /> v-1 {( PHONE# EXT. <br /> BUSINESS NAME fi Cc�u�ct e���r�L yJ / r� / <br /> HOME or MAILING ADDRESS^�,> &i,-7 <br /> `� - Vkle CJJ FAX# 7 <br /> 7 c�( ` ( ) <br /> CITY STATE L/� ZIP <br /> Sly� �v+ <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,�TdDERAL I2W5. <br /> /l ,p, <br /> APPLICANT'S SIGNATURE: ` ��'�� DATE: 7 10--1 / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT A Xe,�7"-- <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tilte <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 /> 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: V25A�Ls PA/Y� ENT <br /> COMMENTS: 10, REVS VED <br /> APR 1 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> RTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: p <br /> Date Service Completed (if already completed): SERVICE CODE: I E: <br /> Fee Amount: Amount Paid l] O — Payment to CJ <br /> Payment Type v S Invoice# Ck# l Received y: <br /> EHD 48-02-025 = SR FORM(Golden Rod) <br /> 07/17/08 <br />