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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SZ.q cç55 <br />' <br />OWNER / OPERATOR <br />il CA a r Zan9aYa <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />/Art Z. <br />SITE ADDRESS <br />531 (0 Street Number Direction <br />mbiriya;-- one C---I- <br />Street Name <br />Sakl ac, <br />City <br />ek6.3 (cS' <br />Zip Code <br />HOME OF MAILING ADDRESS (If Different from Site Address) <br />.g7 10 Street Number <br />1\100(1g +0 rle (4- <br />Street Name <br />CITY /1 <br />5Ck.161,L <br />STATECA ZIP <br />6it -'3 V —g <br />PHONE #1 EXT. <br />(u,k) 311 - g2 9 g <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(2.0q ) RO Ct .., 4A3 t\ <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ii\oAcct '7.ctoi o CCI <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />(-)Ar k 27. <br />PHONEI (2oci 1 /Z- '2-4 <br />EXT. <br />HOME or MAILING ADDRESS <br />)(VICO ack-One Ck <br />FAX # <br />( ) <br />CITY c,c,6 \ 8ct STATE etc 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 Of <br />activity will be billed to me or my business as identified on this form. <br />also certify that 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, STA and FEDERAL laws. <br />APPLICANT'S SIGNATURE:2/ rsr,. <br />PROPERTY / BUSINESS OWNER 0 OPERATOR! MANAGER 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: ft) CA F\ttri (-- Vi„eC___ PAYN Etr --11" <br />COMMENTS: RECEIVED <br />AUG 2 7 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 1 . M Oey'l D EMPLOYEE #: DATE: <br />ASSIGNED TO: 3. C, 01 allt-ESCC2) EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 2._...3 P/E: R.D D t <br />Fee Amount: of3 /4,14 (.0 Amount Paid Payment Date S 27 t 7 <br />Payment Type .. Invoice # Check # Received By: (a9D--) <br /> <br />DATE: <br /> <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08