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Title <br />SAN JOAQUIL _20UNTY ENVIRONMENTAL HEALTh _ ZPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />-- 4 01)2-r-)01-/- <br />Sa,I3V,1 g REQUEST # <br />SRO 1 ift0 <br />OWNER! OPERATOR CHECK if <br />L-5 kik) ic ZliA-4 Sit/zZ Ijc T--k A- / e-c•\ (zt.o 2 2(Ar-i BILLING ADDRESS <br />FACILITY NAME .4 <br />7 <br />' '—/A .4 1- <br />I Pr-S- -VrTrz---;--V7i--Crrt"77re_i <br />SITE ADDRESS <br />.10C-, 7 Street Number Direction I S CM \tic ‘ti'3141a4le,j L vA , 51-DckA-cm Cr-trZfoq <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />O(', --? CD \ , ci U v N , Street Number <br />, , <br />Street Name <br />C17Y-, I STATE <br />----\Or\-cAc ov\ <br />ct z,s_z_a ct <br />PHONE #1 Err. <br />CO Y17 - iciG. <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. BOS Dismic-r LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK if BILLING ADDRESS <br />REQUESTI:4t I <br />k•-)\ oet ; a C s . , ,(\ Q ,)A\0410,/\-(/ e )(1.'\ a. <br />BUSINESS NAME r` <br />sa a)z._ a __r ci. k ( e \ <br />PHONE # EXT. <br />(2 OC O (7 ( 7 - 1 C( Cr ? <br />HOME or MAILING ADDRESS <br />10C,52 3 \ s ti cy L) L,, <br />FAX # <br />( ) <br />CITY ic-O-Y \ <br />STATE( c.„‘ ZIP 9 co ci <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 ENVIRINMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identi ed on this form. <br />I also certify that I have prepared this application a th t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FrDE• laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El OPERATOR NAGER 0 OTIIER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PA Y 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environm / ite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an*t it is <br />provided to me or my representative. ec <br />TYPE OF SERVICE REQUESTED: H,010) <br />. , -•Tir cia <br />if -z)d C.onS (A 1-14/14/1 A v• <br />COMMENTS: SAN .1,-, <br />8 2019 <br />r. ••.-9etQu <br />ii °11/1R0 IN CCVN <br />E4LTH DENZAirk 7)' - . rAfEivr <br />i <br />ACCEPTED BY: La Lit (-0 c;;,. EMPLOYEE #: <br />g -1°— <br />DATE: <br />ASSIGNED TO: Mttiv-) 194 1 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 / PIE: 4.0 0 <br />Fee Amount I 5_.to, Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />DATE: