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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />c.7.0 MOD 11— <br />OWNER / OPERATOR -, <br />--- 7ja-dr064 41r_CO/f-- CHECK if BILLING ADDRESS <br />FACILITY NAME jg, aeeze &F-4ed-- fra <br />Ccgi Street Number Direction <br />SITE ADDRESS C-260 <br />I -51‘76'r64117 e4Street Name 3s/..- City Zip Code <br />Hoi‘q or MAILING DDRESS (If Diggent from Site Address) <br />)<=-. i Street Number Street Name <br />CITY <br />/1 (-77 <br />STATE,, ,/,l <br />ZV <br />-- ZIP c7..z <br />PHONE iii Exr. <br />(,L/)czie -70'75.--- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />rg/d0h /74(ctitt( <br />CHECK if BILLING ADDRESS <br />PHONE # EXT. BUSINESS NAME uee7e 7-p6,ev' <br />HOME or MAit7 DRESS, z , ? <br />/7 1/i _e il -5' Pc <br />FAX # <br />) , ,f( <br />i <br />CITY <br />left- <br />STATE/7 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 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 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 />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAG R 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT 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 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. <br />TYPE OF SERVICE REQUESTED: --COCA \I OM (11) kv\c,vek;A,m, RECEIVED <br />COMMENTS: 0. cumtwomp . <br />DEC 2 1 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Km ACCEPTED BY: 4 .,,,,t0Au viAy EMPLOYEE #: DATE: VZ, z ,.. I \. <br />ASSIGNED TO: (1 ftl EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ''...m.A.._C) \. P/E: U017 <br />Fee Amount: V NC:71_ , n Amount Paid 41 ----(9, _____ Payment Date 1 )4/ <br />/ <br />/ 7 <br />i Payment TypeVv...k, Ald-i-,, Invoice # <br />Cil€(63# S5`i V V1L Received By: <br />DATE: //211t,42 <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08