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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 <br /> -�o�j CHECK If BILLING ADDRESS <br /> FACILITY NAMEV C"L� <br /> SITE ADDRESS 131TW <br /> tA. J- " , �� � yC� oeirection Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CQDE <br /> ( 1 OLS <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 11Je:C-44.ata�A CHECK if BILLING ADDRESS121 <br /> BUSINESS NAME c_.,�C c.L.eL_I��41 Ski <ft(, TLLe PHt}N # ar`y/_�3 Si EXT. <br /> HOME Or MAILING ADD ES T( { pLl w� FAx## l 5 lQ 3 <br /> CITY L& SO STATE ZIP a <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, STATE and FEDERAL laws. j r <br /> APPLICANT'S SIGNATURE: `rV- DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT u <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is nrnvirlari t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: _ <br /> COMMENTS: FRXECEIVEu <br /> AUG 3 1 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: az EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: I� P/E: <br /> Fee Amount: `A cDec' Amount Paid �. Payment Date <br /> Payment Type ✓ Invoice# Check# W'q y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />