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SAN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH OPPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IS 1711 T7 qT7 <br /> OWNER/OPERA R- <br /> n � M I ✓lA CHECK II BILLING ADDRESS <br /> FACILITY NAM (I /l Ci-t_,r�� I C�t/ r bM�— C/1� l�r,/ `^r <br /> SITE ADDRESS r p V'I � V\ � Vj�✓ V ��`''7 �l <br /> Street Number Direction Street Name city ZI Code <br /> HOME Or MAILING ADMEIS�S (If Ifferent from SittAAtltlress) <br /> I- �' "' r' AZT� Street Number Street Name <br /> CITYS( W' ) \ Ul11n\ STATE �+ <br /> PHONIE,#'I ,� ExT. APN# LAND USE APPLICATION# c <br /> ( L4N)" S Mo <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n hct c - v-umk -n; mu,Vt1v)e2 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# E".Sa t I �m ��Y,� ED5195 Zo t_, (, <br /> HOME or MAILING ADDRESS FAX# <br /> 10 1. S. yrclo . d ( ) <br /> CITY AaLkrA- , STATE ZIP n Z / <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,ST fl RAL a <br /> APPLICANT'S SIGNATURE <br /> ,/ DATE: / l `✓� <br /> PROPERTY/BUSINESS OWNER`IJ 49PERATOR I 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, 1, 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 COUNTY 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: VDupyolue/ <br /> S ' ,v 'v <br /> I Dfth.— <br /> COMMENTS: VJJZ <br /> AUC 17 2017 <br /> r� _ LSANN OROUIN COUN <br /> ACCEPTED BY: L . ckn EMPLOYEE#: DATE: q i, NT <br /> ASSIGNED TO: `W ff EMPLOYEE#: DATE: -7 0 <br /> Date Service Completed (if already completed): 1 0101 SERVICE CODE: IPI E: 1 3 <br /> Fee Amount: tDa ,UD Amount Paid I CJ2 Payment Date `-1 <br /> Payment Type 'h Invoice# Check# Receil7ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />