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APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 <br />DATE: <br />OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br />SERVICE REQUEST <br />I <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />"C, COWk•e3 0 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME I <br />J o Ada1/4) 0 LvLIV/AN <br />SITE ADDRESS <br />Street Number Direction <br />)-4---,ii2s1 I ,(1A- Vi G‘,%.1 <br />StreeiName <br />-*YN,) <br />City <br />0 ca) <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />el Li 47 Tug cmAri eiRLIE Street Number Street Name <br />CITY c STATE 0 it ZIP <br />i .S.- 2. I 0 <br />PHONE #1 EXT. <br />(24 q) S-07 - S. 7 7 i <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR i <br />e • A <br /> <br />J 0.4A7ANI vA IQ 1. CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />I As A " 1- 0120,17- 0 <br />PHONE # <br />(20f) <br />EXT. <br />S-07 57 7- / <br />HOME or MAILING ADDRESS <br />CI 4 Li 7 TO C ER-C. 1. E <br />FAX # <br />( ) <br />CITY ST o e x.....r 0 Ai STATE 6/A ZIP ei s-216 <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 work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST and FED AL laws. <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <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 pr_ogHp me or <br />my representative. PAYM <br />TYPE OF SERVICE REQUESTED: MC bV1,Via EA) V I i t;tr RECEIVED <br />COMMENTS: MAY 1 6 2019 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: \I - WI ov\QAA, 3 EMPLOYEE #: DATE: 05_( (619 <br />ASSIGNED TO: <br />\I A Wed_ 0 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ao I P/E:IL0 3 <br />Fee Amount: * Is? Amount Paid v ,--, _ — , - Payment Date ---"---/ / <br />Payment Type Invoice # <br />( <br />Check # Received By: FiLl <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08