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APPLICANT'S SIGNATURE:)( <br />PROPERTY / BUSINESS OWNER EI <br />0 14 / cAk <br />OPE ATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />11 DATE: <br />SAN JOAQUIN C‘.,(JNITY ENVIRONMENTAL HEALTH DL. ,tRTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Se_ 00-Z\ 3c1 2-- <br />OWNEA / OPERATOR <br />I \ -\"\Thix-:\ 0 Cc \ i\C\C\ C_\"-<> i\J\ mi c-) li\ c) <br />CHECK if BILLING ADDRESS <br />FACILITY NAME L._ ,-- I <br />\ .\) c(-4e.r\cA "-_-_-_ <br />SITE ADDRESS \ 0 ?..._ 0 <br />Street Number Direction <br />i\j"\0\--\\— \C"._\ CA 0 r <br />Street Name <br />N•ik\es- <br />City <br />oi s a <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />\ CLO <br />Street Number <br />N\ck--Ic \i-N-A CA Or <br />Street Name <br />CITY <br /> <br />STATE c ii.\__ ZIP <br />PHONE #1 EXT. <br />( 2-A CO <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO R <br />tr-\ A CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE 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 and FEDERAL laws. <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 environmentili5i4e assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avai9Airlit4tt tame time it is <br />WED provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: '('-12....Aj3 \.) Q__\---' Li-52 C--k -NIN. \-i \—.0--4 1 3 2019 Nov <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />L \ r\ \(0\ ("e <br />EMPLOYEE #: DATE: ( \ - 3_ q <br />ASSIGNED TO: (__;, (\\\\Q\( e ‹, EMPLOYEE #: DATE: \ \ .- 9 <br />Date Service Completed (if already completed): SERVICE CODE: 0 Ic..._) \ P I E: A <br />Fee Amount: \7 _— <br />Amount Paid s 2 _ Payment Date - <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003