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EXT. <br />BUSINESS NAME Lc ck&CCS t) PHONE <br />6111-11)-c- Li- or <br />FAX # HOME or MAILING ADDRESS • - I 1 J • ,`"j <br />STATE Ca-- ZIP 01520 Stocy.Auf, Crry <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />rA)t)_0,\__ )1FhiCHECK if BILLING ADDRES <br />• <br />SAN JOAQUIN - _,UNTY ENVIRONMENTAL HEALTH SARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />k--Ood 1 fail-ex <br />FACILITY ID # <br />f.)a, ‘) <br />SERVICE REQUEST # <br />c.3 (c) ct2:7c0 Li 1 <br />OWNER / OPERATOR <br />CA-1st/AD1A1 \ A 11 Cc CHECK if BILLING ADDRESS <br />FACILITY NAME 1 _ <br />Ldt) COrYI p act res . <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />VA 'b.-2- Street Number <br />M on-\-akaq. <br />Street Name <br />CITY r, STATE ZIP <br />.3C-OCV-A-Dn C a 671 2 DS <br />PHONE #1 Err. <br />(zol) 2018- t D13 <br />APN # LAND USE APPLJCAT1ON # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <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 and FEDERAL laws. <br />\C.OL(.> DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />APPLicAN 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 ENVIRONMENIAL HEALTH DEPARTMENT as Soon as it IS available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: \ci, v\ ( \ ac riitT nntN 1 <br />RECEIVED <br />COMMENTS: <br />JUN 07 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:(, ici EMPLOYEE #: DATE: ic 7. / 'is <br />ASSIGNED TO: 1--) -e_f i EMPLOYEE #: DATE: 4.. 1 _ / <br />Date Service Completed (if already completed): SERVICE CODE: z32 ..2) P1 E: )/c C / <br />Fee Amount: t,\C-DV/ Amount Paid LIT-6 — Payment Date b . 7 • c-j <br />Payment Type .1r1F)Li Invoice # Check # — Received By7r'------ <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003