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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I <br /> OWNER/OPERATOR /� /� <br /> ` v�GedV C Gcevi I as CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> XOckicalco Tg400 & C cS <br /> SITEADDRESS cj3C73 O�CIIC AVe S�Ck'f01� �� g52o9 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ���� F�c>✓i'�f �� <br /> b7 o 6 Street Number �t Street Name �Jc <br /> CITY S+oc r �P STA T ZIP _752-07 <br /> 9 K l_ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2019) 6 - q 47 <br /> PHONE#Z <br /> EXT. BOS DISTRICT LOCATION CODE <br /> cwt) o -61 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> G mI d oVem CHECK If BILLING ADDRESS <br /> AA e <br /> BUSINESS AME u i / PHONE# EXT. <br /> xoch/co <br /> HOME or MAILING ADDRESS /I FAX# <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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,STA/TEE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ���� '!'�/ � I' DATE: 12-7—/? <br /> PROPERTY/BUSINESS OWNER 5� 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 assessmentn <br /> �' <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provlA® <br /> my representative. •!e`7 �T <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ✓o 8 <br /> II y�CIRON,N COU <br /> I yoFP �� ry <br /> N <br /> ACCEPTED BY--Z C EMPLOYEE#: DATE: i L <br /> ASSIGNED TO: -J.+ EMPLOYEE#: M Y DATE: <br /> Date Service Completed (if already completed): I SERVICE CODE: 66I P/E: b <br /> Fee Amount: �2, y� Amount Paid i, � =Payment Date IZ <br /> Payment Type Invoice# Ch ck J J Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />