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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# QSERVI E U # <br /> tzF-S-T amu.aNNT -D z L I S� <br /> OWNER/OPERATOR <br /> 9 J A / O CHECK If BILLING ADDRESS <br /> FACILITYNAME <br /> 1 0 120 41 �N 1�N C U <br /> SITEADDRESS S C <br /> lyu C-Cm fC0-/F C C 0r'1f7c1ZGc c12� L� i Ik�II vt �S��ry <br /> Street Number Direction Street Name cityZi Code <br /> H�yl1y!�A�Ejor or ADDRESS (If Different from Site Address) <br /> l,�J C U�Ot I C-2-. "V J Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (� ) 2.01 -G7g-��BI 021- 04c - C) C) <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> '--'r t\(:�'1'," 3 ki —, I P, CHECK if BILLING ADDRESS <br /> BUSINESS NAME _ P20EXT. <br /> c# <br /> HOME or MAILING ADDRESS FAX# C� <br /> CITY 2�CLr STATE �� ZIP <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 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 o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stand rds, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURET' DATE: 3^ZS_t c� <br /> PROPERTY/BUSINESS OWNER —OPERAT R/MA AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required 7 frtc <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 /> to 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. P&MENT <br /> TYPE OF SERVICE REQUESTED: �� RECEIVED <br /> COMMENTS: <br /> / (��i�1 Sa`4 - CS90 �/V/� 3a MAR 29 2019 <br /> I t A/ fi9 IZ SAN JOAQUIN COUN ry <br /> SPy eh)tl ENVIRONMENTAL <br /> HEALTH DEPARTME 4T <br /> ACCEPTED BY: �j 'n EMPLOYEE#: ' DATE: 3 9 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: �� l <br /> Fee Amount: 0V Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />