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SAN JOAQ, COUNTY ENVIRONMENTAL HEALISEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# /SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> 1-'2 n <br /> FACILITY NAME <br /> LG S Mc+ C� S <br /> SITE ADDRESS <br /> 1 0 Street Number ection rG�l�C Street Ne Sfio <br /> L city <br /> HO E oorMAILIINNG ADDRESS (If Different from Site Address) <br /> I �" v/ ``k-k D CI`e Street Number Street Name <br /> CITY STATE IP <br /> C to C A G �S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Q0I) to 0 � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �L.� e,< J� CHECK If BILLING ADDRESS <br /> BUSINESS NAME -V PHONE# EXT. <br /> La's MO.t2\s 2(X '"g6S6 <br /> HOME or MAILING ADDRESS FAX# <br /> S to b IR-rAu e =<<s kxr6 FA ( ) <br /> CITY st, -t-on STATE C ZIP q os- <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 nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I" Z �� / <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ 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 and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED���( <br /> COMMENTS: NOV 2 5 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �,U EMPLOYEE DATE: <br /> ASSIGNED TO: �C(1 I�nC�v JEMPLOYEE#: DATE: 7 <br /> Date Service Completed (if already completed): SERVICE CODE: ty P I E: , <br /> Fee Amount: iCjL 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 />