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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S12 oD 3 ofd-4z <br /> OWNER/OPERATOR n to e1 M� <br /> cfi n CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS q 2-1( LV�12G'1\�� /� �"��' 61c3'3-77Street Number Direction Street Name Imo- city/"(� Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 02,--;� LAD <br /> Street Number Street Name t'L <br /> CITY -- -V/y� STATE CA ZIP <br /> PHONE#1 6'� ETT. APN# LAND USE IAPPLICATION# <br /> ( ) I -Iq o(C' 2A <br /> PHONE#2 EXT. BOS DISTRIC,�_ LOCA CODE <br /> ( ) (l/{N`yc, > C21 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR U j n /� ^n ^_ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PONE# EXT. <br /> COL4 G-S3(4 u <br /> HOME or MAILING ADDRESS � t ,�n��' FAX# <br /> CITY oit tb'f.1 ^ - STATE C ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent lof 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,XPERA <br /> nd EDERAL IawS. I l G <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OR/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 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: O �� s RECEIVED <br /> COMMENTS: APR ^ 9 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: y fVl ��`J EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already compieted): SERVICE CODE: C5- 2-3 PIE:ZoV�— <br /> Fee Amount: �Q(} Amount Paid 'O Payment Date <br /> Payment Type Invoice# Check#a2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />