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Title <br />SAN JOAQUIN UOUNTY ENVIRONMENTAL HEALTH DEFARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID it SERVICE REQUEST # <br />5 ROO 5'/G 5 I <br />OWNER! OPERATOR <br />CHECK if <br />F-ra n CA_C C_. PCa) 10 C-134A-Q-7-- BILLING ADDRESS IZI <br />FACILITY NAME <br />SITE ADDRESS t <br />Street Number Direction _ Street Name A.1-k.A.1/4_k_ <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) k <br />Street Number FA,,y-Q__,------A.- Street Name <br />CITY c-, STATE ZIP .__ - <br />(1 PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />(5c . .<2 k--C 0 .2 <br />BOS DISTRjcT <br />CO -2--- <br />LOCATIONor DE <br />C't <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Cm n cA 5 co 4,301c C...:3 Ota.z_ CHECK if BILLING ADDRESS 132 <br />BUSINESS NAME 1 e c _)' Nrc\_2:... \A <br />PHONE # <br />(Cic) <br />EXT. <br />HOME or MAILING ADDRESS <br />I Y2- -4 G • qs---,-k-v\ `-' C <br />FAx # <br />(.c) c-tv-.Ck 4.1 S I <br />CITY STATE ZIP <br />(--- <br />,_ R ---- <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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATES FEDERAL laws. <br />DATE: <br />PROPERTY / BUSINESS OWNER pi OPERATOR/MANAGER OTHER AUTHORIZED AGENT 0 <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 provided to me or <br />my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: :0:5 6k c-rc) I.Ctin Q KR-C-Y---- RECEIVED <br />COMMENTS: <br />NyeA,.,f 4_h ( c I 1---, AUG 1 3 2019 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: e6,(Ci. EMPLOYEE #: DATE: '5 . <br />IS- <br /> 1 9 <br />ASSIGNED TO: 4 cevecio EMPLOYEE #: DATE: `T). I - I c7 <br />Date Service Completed (if already completed): SERVICE CODE: 5 z -... P/E: 1100 ) <br />o•G Fee Amount:.. Amount Paid Payment Date <br />/(// <br />Payment Type ‘,, , Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)