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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESTi# <br /> 1.4 LGE ,2ESoQ.T Jp o oo <br /> OWNER/OPERATOR <br /> A ^ Z- / /G L 424--- /-G C, <br /> FACILITYfNAME ` �L CHECK If BILLING ADDRESS <br /> C.4 I GAGE 5 2F Sot° <br /> SITE ADDRESS /o?, �Q�ZE��E� Tl2A5394 <br /> Street Number Direction Street Name Ci Cl/ ,IpCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 4 71 Q 6(J,A(- L A k-jF]! P jZ s TIE <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> O C(L A jo20 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> P4,P 2 - —03. 06 IPA - 100vVlol, 5a 00 (G <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR T <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME t/ /V L PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITYSTATEC ZIP -5--? <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 KPlication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, StandardsTE and F RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ,, ZZ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 COUIJTY 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: rW <br /> %Tt7A7�L NC L E <br /> COMMENTS: <br /> AN�o 2019 <br /> FNVjgQ�hv <br /> N�CTy pM FNTq)NTV <br /> ACCEPTED BY: EMPLOYEE#: v.' DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: G <br /> Date Service Completed (if already completed): SERVICE CODE: Z -5 P/E: <br /> Fee Amount: O Amount PaidPayment Date Z <br /> Payment TypeAI <br /> ( - Invoice# Check# ':�l Recei ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />