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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW E /OPERATOR <br /> CHECK If BILLING ADDRESSE] <br /> FACILITY NAME P,m e T I LC(n <br /> SITE ADDRESS \1�AYp.I�_ Lavine <br /> 4 Street Number Direction "T Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3�30-1 Street Number Street Name <br /> CITY STATE ZIP <br /> d1 I Si( <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ('2��A) 61<�-Lk' `S z 1 S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME , 1� 1 PHONE# EXT. <br /> 'nv�neklCG�� <br /> Coj 2LJ �Sz1'- '8215 <br /> HOME or MAILING ADDRESS FAX# <br /> 0 <br /> CITY ({�r O ^ $TATE C ZIP G�S� <br /> BILLIING 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 /> 1 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAWEdO OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available antime it is <br /> provided to me or my representative. '��ff <br /> TYPE OF SERVICE REQUESTED: LO✓lS�� (��� <br /> COMMENTS: 2019 <br /> JOAQUIN <br /> Hq0NCOU VMR e5A47Zp . <br /> ACCEPTED BY: 1 v1J\��/� In� EMPLOYEE#: DATE: 'tom <br /> ASSIGNED TO: • vt V EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: b` P I E: W2 <br /> Fee Amount: I Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD SED 11/1 '- �J I 0 I ( ( O� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 /lam' IUILI IU(CJ <br />