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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 31)y APT 3K(7t-� Tq ( 55 <br /> OWNER I Q PER�ATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME fl0114 1/LIC U P "/q <br /> SITDc,D�1RESS -r— / C,y/` 7 <br /> I r Street Number Dir�ion U �� reet Nam1 �� cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 0)9) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST-QR <br /> j5 nl P,t , ? i L 7D 67tl <br /> CHECK If BILLING ADDRESS <br /> BUSINESS E //'/ C>W V V l PHONE# EXT. <br /> AtELa14 A K LOA <br /> HOME or MAILING ADDRESS FAX# <br /> ,-,2L11 E. 16T 5T �Et 3 c ) <br /> CITY ` STATE 14 ZIP g5—:E'>-7 <br /> `-,e <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, <br /> APPLICANT'S SIGNATURE: Z�� <br /> / G <br /> DATE: ` <br /> PROPERTY/BUSINESS OWNER t� 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided t0 me Or <br /> my representative. R"- MENT <br /> TYPE OF SERVICE REQUESTED: Ca-lc-��J - RECEIVED <br /> COMMENTS: Choylcf 3 ' Zw -Fac-1U, <br /> al JlU I"t''A L 3 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:. a EMPLOYEE#: DATE: 5 n <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: VL2 , PIE: <br /> Fee Amount: I ) �_ Amount Paid I)—a Payment Date S• a 3 I <br /> Payment Type De-b.t Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />