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SAN JOAQUIN (..JNTY ENVIRONMENTAL HEALTH DE_ ..RTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY <br />/76-7 <br />ID # SEBVIcg REQUEST # <br />R D(16 I -7-(aq <br />OW <br />' <br />/ OPE <br />e <br /> <br />p <br />R <br />CHECK if <br />I )cili a <br />/41 <br />/i e <br /> <br />_ <br />NE. <br />BILLING ADDRESS <br />FAciLrn NAME <br />, I do <br />z)a6ie &- o s .(prricte3 .3) <br />, SITE ADDRESS <br />, Street Number Direction fiwe ee Nattil /go- ii ' -,(74e 9*-:f-ci,f <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />kC' / 7/ 7 57 6f4/6')/7 / , Street Number Street Name <br />CITY TE <br />(F <br />STA <br />PHONE #1 / Exr. <br />62 9 56V . j-haq <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUE§TOR <br />c/J a L//l i ' el) CHECK if BILLING ADDRESS El <br />BUSINESS NAME <br />i ae 8 J2.-)11S3 aynea5e,faec3 " 5 <br />PHONE # <br />c_,10ii 5Pq • -i--/eXP9 <br />EXT. <br /> <br />HO,MING ADDRESS . <br />_. -' 442- <br />/85 <br />FAx# <br />( ) <br />CITY STATE ("Va. 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 wor o be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stan, , STATE and FEDERAL I s. <br />APPLICANT'S SIGNATU <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 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: 00 n1A (iild C/OnSIA-1-1-410(1 <br />CommENTs: RePcjiwierfreb <br />FEB 1 9 2020 <br />sAN JoAQuiN ENvilioN -- coutgry <br />HEALTHDER4IENTAL <br />EMPLOYEE #: qf g.,,70 DATE: I ACCEPTED BY: La (if Ca <br />ASSIGNED TO: i<C-f far 11 f L, . EMPLOYEE #: Li, S 8-6, DATE: <br />Date Service Completed (if already completed): SERVICE CODE: OCif i PIE: (...,, <br />Fee Amount: 4 12-6(, Amount Paid , _ Payment Date <br />Payment Type Invoice # Check # Received By: <br />bATE: <br />PROPERTY / BUSINESS OWNER Er- OPERATOR / MANAGER NI OTHER AUTHORIZED AGENT 0 <br />END 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003