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t t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID# SERVICE REQUEST# <br /> 3� D6-77 gcf)3 <br /> OWNER/OPERATOR o <br /> un, Ved 1 Ll el' <br /> F i C• CmEcac it ENunto Apawss1..J <br /> FACILITY NAME 6 q e 1 /p_ <br /> SUE ADDRESS ""( f, �p[�f'► y ��L)�'j ��1/Cr- c�f-d G�'}�{1 q' g�()1 <br /> Street Number DI ZJR C <br /> ade <br /> HOME or MAE.iNG ADDRESS (If Diffemnt-frrom Site Address) <br /> v e'K 61--• Stmt Number S <br /> trowt mom* <br /> CITY L n Oe4 t*P) STATE zip <br /> PHONE O0,T APN# LAND USE APPLICATION# <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> ( ) —C1 q7 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ppa� <br /> Gra Cx if BILLw6 Afloat ss 11 <br /> BusiNEss NAME 14 y enov/ /�t��a Ite r✓fcc qnd F U�p. �P PNS y3?''� �. <br /> HOME or MAILING ADDRESSO FAX <br /> / /i� p �d � ^7 (7,07)q37 -4557 <br /> tirrY VA e a.V, I `ei STATE /1A- ZIP W 6 a 3 <br /> DING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific E?mRONMENT'AL HEALTH DEPARTMENT hourly c <br /> or activity will be billed to me or my business as identified on this form. st <br /> I also c that I have application - °� <br /> certify prepared this a hcation and that the work to be performed will be done in acca cti artth al�SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE and FEDERAL laws <br /> /)UL ! i 2017 <br /> APPLICANT'S SIGNATURE: �I DATE: �_ —] <br /> PROPERTY/HUSINESS OWNERO OPERATOR/MANAGER O OTtmR AUTHORIZED AGENT❑ E W/ R C U j,I E NTA I HEALTH <br /> If APPLICANT is not the BILLING PARTY.proof Of outhojiZatiOn to sign is required nP� T^���T <br /> R di <br /> AU RIZATIO TO LEASE )FORMA N: 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENvmoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: —r' lL <br /> Pp��(N1E <br /> COMMENTS: <br /> JJJJ_ 2 2017 <br /> SAN JOAGUiN COU <br /> L(`l <br /> 'Ak i UEV'i �w ST <br /> HEAD-TH <br /> ACCEPTED BY: EMPLOYEE M DATE: "7 /7-/-7 7 -7, <br /> ASsiGNED TO:--V-2,;J ef-g EMPLOYEE#: DATE: —/-17-/ 7 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:, , J <br /> Fee Amount: (I! Amount Paid a Payment Date a ' <br /> Payment Type G Invoice# Check# Cl a 1 g 5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17IM03 <br />