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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />:606 --nrkkiy_.„ <br />FACILITY ID # CtDIIICJ pFnIIFST # <br />.> <br />OWNER / OPERATOR IN m neiVA ‘-v1 CHECK if BILLING ADDRESS way, vornre.„2- <br />FACILITY NAME Toicif -DT\ kk orb <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />Q. <br />HOMi,E*Alr Arm6Different from Site Addrqss(4. <br />giire Street Number Street Name <br />CIA:7x cp.c.).!TE <br />PHONE #1 EXT. <br />CA <br />APN # LAND USE APPLICATION # <br />PHONE #2 #2 EXT. <br />WI ) (124-ta rriPi(Ok <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR wknei1/4 IA v-Anroe)2- CHECK if BILLING ADDRESS <br />BUSINESS NAME km-ux -van vilo EXT. P(71#) (st_witim <br />FAX # <br />( ) <br />FtwArrayou., ukre.,*4 <br />CITY LOVA (ATATE ZIP cre„,04.4C) <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 />also certify that 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 FEQERAL laws. <br />APPLICANT'S SIGNATURE: \a DATE: 270 \ <br /> <br />PROPERTY / BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />Title <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 to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: M t I it /D0d) [Aar) CMCCK REceNED <br />COMMENTS: <br />jus A 2 2019 <br />jof,cluilicc)u S ml AN ENVIRONMENTAL <br />- ..,„, DEpARTNO HEALin <br />ACCEPTED BY: Lc{ rq EMPLOYEE #: Cl g -5/2 DATE: 5/36)// g <br />ASSIGNED TO: ,) Ff C EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: v 5p.9 P / E: /0,0 / <br />Fee Amount: S IJ(9 Amount Paid Payment Date / )__ / 7 <br />Payment Type 'J i kW, - Invoice # Check # Received By: <br />(N tL)Jr- <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)