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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 DDS I 5 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESSD <br /> EOOEZKZ50/4s REAPIV m x <br /> FACILITY NAME <br /> SITE ADDRESS /0,50[? S 11,4 IUAV R 0,4-. 1�1_ZEIVCA/ eA&7P1 <br /> 5 <br /> a 3/ <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Cole SOGt'Tiy/l7i4I""' 5-7 Z'57 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Cexoiv A eA 9a8 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (qsl ) kO-425-3 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Do/y, / CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> Lr/nlC oz- ,6s <br /> HOME or MAILING ADDRESS FAx# <br /> 0 130Y 37q4- <br /> CITY z/ STATE CA ZIP S.3 <br /> el <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and./or project specific ENVIRONME..NTAI..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,Slandarcts, 'I=and Zf .21Al.. laws. <br /> APPLICANT'S SIGNATURE: DATE: 30 119 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTFIF.RAUTHORIZED AGENT0 <br /> If APPLICANT is nol 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 COUN'T'Y ENVIRONMENTAL I IEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> REQ MFNr <br /> F/veb <br /> DEC 3 0 2019 <br /> ACCEPTED BY: EMPLOYEE#: l <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1,7WWn .—NW117 <br /> NT <br /> Date Service Completed (if already completed): SERVICE CODE: —.5 a--3� P 1 E:-Z602, <br /> Fee Amount: O�j Amount Paid 08 Payment Date .Z. <br /> Payment Type Invoice# Check# O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />