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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C'D C L L SQ 00911 1- H <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADpRESS <br /> /r9 17- - v,4 N l K FA tz7A m E E <br /> FACILITY NAME <br /> T u.c A t_ <br /> SITE ADDRESS F:/Z CN ('A/'l'lP /ZQgp FKaAk-,/ 4Anel g533� <br /> Street Number Dirrection Street Name City zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 17 q pO n7 k 2 PH! VA IZ14.W 4 y <br /> Street Number Street Name <br /> CITYI—^Try IZO l' STATEC ZIP S <br /> P�Hp NE#1 /� E'�' APN# LAND USE APPLICATION# <br /> , ) Ig3 -42 70 - PA -16002-57 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR/)7//,, <br /> 2• CHECK if BILLING ADDRESS <br /> BUSINESS NAME PH NE# ExT' <br /> ftz,eAlc a Ruct< L 8 3�S-S�7ov <br /> HOME or MAILING ADDRESS FAX# <br /> l 7 0a m a AP w ( ) <br /> CITY STATE eA zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and project specific ENVIRONNIE..NTAL HEAt.TEt DEPARTMF.N'r 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('odes,Standarels, STATE= d FEIN RAL laws. i Q <br /> APPLICANT'S SIGNATURE: DATE <br /> PROPF.R'ry/Bt;SINE55 OWNE.RET--/ OPERATOR/MANAGER ❑ OTHER AU r1I0RIZt n A(:F•N'r❑ <br /> 1J APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable. 1, 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 ENVIRONMFNTAI E IC:AL't'Ei Di-r)ARTNIEiNT as soon as it is available and at the same time it is <br /> provided to me or Iny representative. FIMMENT <br /> TYPE OF SERVICE REQUESTED: SOt L f u 1 TAp(L/r N/r kATTr Z40ADg") <br /> COMMENTS: <br /> DEC 0 6 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE:If 41 <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: <br /> Fee Amount: Amount Paid 6 — Payment Date L <br /> Payment Type Invoice# 7 Check# D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />