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SAN JOAQUIN %.,OUNTY ENVIRONMENTAL HEALTH DEN-ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1 u'LL.L.; \ X - u <br />FACILITY ID # SERVICE REQUEST # <br />OWN1:2 / OPERATOR 1 , CHECK if <br />LX.("V-IY di k„f )10 V, 0 <br />BILLING ADDRESS <br />FAciLITY NAME , LC" C.- 1‘ <br />SITE ADDRESS ADDRESS <br />Street Number <br />`5". t -1 <br />Direction ,c---k--`t 1.koc-Y-k v\ ic,r(D lessf&D y- <br />reet Name <br />Locti <br />City q- 2-40 ip Code <br />HOME or MAILING ADDRESS (If Different from ite Address) <br />0 C-k-1 tit ()Lk r-- n V Street Number C- A Street Name <br />CITY STATE ZIP <br />61 c2-"0 , .9: <br />PHONE #1 EXT. <br />( Z1-741) 1-(2--- \ i <br />APN # <br />7 " v()5c? <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEFOR 0 <br />( kXL on <br />fl( Ire, (6 0 UAV1 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 1, PHONE # <br />( -24)9 ) <br />EXT. <br />HOME or MAILING ADDRESS , HOME <br />C "- /U 0a-A Y1C1 -lo k Y- 3) 'Pr <br />FAX # <br />( ) <br />CITY I I,,( l <br />STA TE <br />C.--VI <br />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 />DATE: 6//y <br />PROPERTY / BUSINESS OWNtitEr OPERAT R / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, 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 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 saktiitgoyided to me Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: --/ RECEIVED <br />COMMENTS: '4 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />L <br />Date Service Completed (if already completed): SERVICE CODE: P/E: <br />Fee Amount: Amount Paid 14-S-(19 • ciii' Payment Date (.0 (Lk 1 <br />Payment Type/ i 0_ _ Invoice # Check # Received y:Qic)Th) <br />APPLICANT'S SIGNATURE: <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08