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APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNERI4 OPERATO <br />2-027 DATE: <br />OTHER AUTHORIZED AGENT 0 <br />1f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />MANAGER 0 <br />SAN JOAQUIL -I OUNTY ENVIRONMENTAL HEALTH .PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />,S(<)O004 (ilq <br />OWNER /..OPERATOR <br />44,1 k". ... a..biel.-C-c--1— <br />CHECK if BILLING ADDRESS <br />FACILIrME(,,, <br />if,G.-fid -(0 <br />SITE ADDRESS <br />1--, i Street Number <br />61( <br />Direction Street Name ...).-i-- 2.-0 de' <br /> <br />City <br />9rel-(d <br />Zip Code <br />HOME Or MAILING 9DRESS (If DifWen fromite Address) <br />it'Ve*I1/1 /If. <br />1 _ / <br />Z-4" 6eet Number t/Y34,11-4,t Street Name 9....St-OlY0 <br />CITY Z., T . ZIP (A.Tp <br />f Cid <br />PHONE #1 ExT. ' <br />(401) .1Z- /0,Y7 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RECII2EVOR _ <br />MAA4),/ <br />CHECK if BILLING ADDRESS Er <br />i ‘I BUSINES) N AM <br />7 wf A) <br />PHONE # <br />(ail) 7.--1S -1/0c-7" <br />EXT. <br />HOME Or MAILING ADDRESS. i FAX # <br />CITY / STATE/74a ZIP <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 />//700 <br />eLt/i4-e K <br />Tile <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. <br />TYPE OF SERVICE REQUESTED: Nit(101 4 -Ric() CO113(Aili-a4-1)t1 <br />COMMENTS: <br />sAiv:A:77N:0 <br />ilstviiiriDolvw <br />Reteivf hov i 6 2019 <br />ou Nry <br />NTAL <br />n 61alrivr .ATE: <br />DATE: <br />ACCEPTED BY: [ CflAra _s. EMPLOYEE #: <br />qg.211(.) <br />ASSIGNED TO: <br />0 a( v) c ,__c'. EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: 0 62 i PIE: <br />Fee Amount: 19-:(b) Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003