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SAN JOAQUIIV COUNTY ENVIRONMENTAL HEALTH bGPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 46+J-1pa S S�omg I v <br /> OWNE.R/^/OP kAT0R �. <br /> 1 / 1 to fres Jose o rre J CHECK If BILLING ADORES <br /> FACILITY NAME <br /> SIIEADDR SS 9 <br /> Street Number rrection+++ion —Street Names'"-� Cit Zi Coft <br /> J <br /> HOME or MAILING ADDRESS (If Different from SiteALfdr <br /> / ess) n ���� C-t <br /> Street Number s Street NJa /� <br /> CITY S `_) $TATE zip q%2-or, <br /> PHONE#1 XI IVEXT' APN# LAND USE APPLICATION It "/ <br /> (20?)�Z $' 1_n'Jg <br /> PHONE#2 ' �d0 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> TVI Or Yt' CHECK if BILLING ADORES <br /> BUSINESS NAME G PHONE# �^ re EXT. <br /> HOME OrMAIL NG ADD ESS V �{(- F # (•(Q <br /> D r ale- f�0t)a13I-<oa <br /> CITY L STATE�r �y 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 I have prepared this application and that the work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER Zf Q ERATOR/MANAGER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the ILLING PARTY,proof Of authorization t0 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i`�p tl o me or <br /> 1IPPAmy representative. �p�EIY <br /> TYPE OF SERVICE REQUESTED: (AV, <br /> W LM EI y E® <br /> COMMENTS: JUN <br /> 2 r. 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> V I J V d�(jJ <br /> ASSIGNED TO: U.�' - EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I "(/ Amount Paid C,D.•OD Payment Date <br /> Payment Type Invoice# Check# Received y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />