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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAoi�i5+3�- SQ� �Z3ti�o <br /> OWNER/OPERATOR <br /> �//1 nv /ti")� CAL <br /> A - .1 ..� CHECK If BILLING ADDRESS <br /> FACILITY NAME `�`/l/G M1 IIV.��. 1.vl'�V/N�,(/ <br /> SITE ADDRESS 1� �,15 1' �'I,e �5'Z2:. <br /> Street Num'Ilber Dlrectlon (J`N� Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> T Street Number Street Name <br /> CITY STATE ZIP <br /> K on C `� 520 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (6/y ) - 449 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR M(A � Lk � .e l-C 11 „�1.2.jCHECK If BILLING ADDRESS <br /> 12j � C . , ,/ 5 <br /> PHONE# EXT. <br /> BUSINESS NAME /AdCklnl_p�� S `/tp ,��I iO4� T ��� G <br /> HOME or MAILING ADDRESS �G%'c- tCJIG l_ 'r"�/ FAX# <br /> rJ l t ( ) <br /> Cm STATE ZI <br /> c <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 <br /> or 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 /> APPLICANT'S SIGNATURE: 'CQ wxivt C ( )e \O' �:Qi ie. — DATE: > '7/VQ/2120 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPL/CANT 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 <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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available 1S4 at tithe same time it is <br /> provided to me or my representative. q c <br /> TYPE OF SERVICE REQUESTED: �'� N 1 <br /> ckav4W VY�N lkccje/!� <br /> COMMENTS: it , _ n nA Jut f <br /> I1vrM1iYtY/ tF1/IL 1I\ sAro,, 20 2020 <br /> FgQUI/V CO <br /> h$ACTj.��EpM� t 1Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: „ I, EMPLOYEE#: DATE: "V <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: i 2 <br /> Amount Paid �5� �� Payment Date <br /> Fee Amount: 4 M— 712-612D <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />