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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERACE REQUEST# <br /> OWNER/OPERATOR <br /> C.A t D I N L• CHECK If BILLING ADDRESS <br /> FACILITY NAME ^� 1 1 i ' Cv <br /> SITE ADDRESS IS O ��M O 'kG�v <br /> Street Number Direction a \ Street Name Cit Zi Co�d/e V <br /> HOME or MAILING ADDRESS (If Different from Site Address) (� <br /> V,J 1 <br /> Street Number Street Name <br /> CITY L066 STATE / zip tq <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( 1A9> Zlo-ZSoI 417-'Z7o-1to-c)ao <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 3 - - 377 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> z—w4t <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 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 tha� wor , e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE nZFDD L laycs� <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNER OPECR/M AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is qol the L�1LL/fG PARTY,proof of authorization to sign is required / Title <br /> AUTHORIZATION TO RELEA0 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 COUNTY ENVIRONMENTAL HEALTH 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: T <br /> COMMENTS: vt�D <br /> DEC 3 2019 <br /> SAN JOAQL/ <br /> ATOC <br /> 7VIYELNF"F/ L <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Compl ted (if alrea y completed): SERVICE CODE: P I E —2,1 <br /> Fee Amount: Amount Paid Payment Dafe <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ' L �2 V V✓`-� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />