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SAN JOAQUIN COUNTY F,NVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 91AQ Qv q `F_C.6 <br /> OW ER/O ERATOR <br /> V1 10EJVI IM Z CHECK If BILLING ADDRESS O <br /> FACILITY NAME A ! 1 <br /> ­�—vot- t ISS n. , <br /> SITEADDRESS ''?J�� \J/ "-4C,c. p� fl <br /> Street Number Direction ,PP_QA Str t Name C``it Zip Code <br /> HOME or MAJUNG ADDRESS (If Different from Site Address) 2y U ZIDS(ovev4 CT <br /> 1 Street Number Street Name <br /> CITY �` CCS in STATE /� ZIP qS 2_0,6 <br /> PHONE#1 EXT, APN# LAND USE�APPLICATION# J <br /> 2T 1 y 3 l 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCgN f E <br /> ( q) 6S2--- -76 "Z 6 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 � T/<,,D CHECK If BILLING ADDRESS <br /> �T <br /> BUSINESS NAME / //� �ij `e1 r� PH NE# _�; E.T. <br /> HOME Or MAILING ADDRESS /L LC ®t /— FAX# <br /> S0 l 14 vC ( ) <br /> CITY C- STATE -7 ZIP /J 062 <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 <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,Standards,STATE and F DERAL ws. G� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BuSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ &l=CTO"` Of 02`_-4A/e0<S <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 COUNTS, ENVIRONMENTAL HEALTH DFPARTMENT 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: V1 <br /> COMMENTS: IVECE/��� <br /> FD <br /> OCT 4 2019 <br /> 8MJOAaU1N <br /> ACCEPTED BY: EMPLOYEE 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Pee Amount: (,o 60 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />