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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prr� t �I � �,� SERVICE. REQUEST;Ow�� � J <br /> Louua <br /> OWNER/OPERATOR <br /> SO(-'J <br /> J V r01 ' V V1 A-k-C c_ ¢Z CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> �aca 5,:Lh�t <br /> SITE ADDRESS c ' <br /> �3 L 70� Cp. I l , c r✓l l�. �� S—ho L ►577 � 9 t� 2 v'3 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 0 <br /> � V;rStreet Number Street Name <br /> CITY STATE ZIP <br /> c.k-Fo <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ('Z&5 (461 - y L( v L <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> J � a -97 c� <br /> BUSINESS NAME � n d^ �� � PHONE# ExT. <br /> HOME or MAILING ADD SS // �•f FAX# <br /> CITYd ST TE ZIP <br /> eA <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, STATE and FEDERAL laws. <br /> 11 <br /> APPLICANT'S SIGNATURE: .tip9� DATE: F�2-T I I <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Ti rie <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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: E® <br /> S o c,o rro ---)-o c M-0- C�-' ry'- MAY 2 4 2019 <br /> SAN JOAQUIN CO <br /> HEAL H p paENrA�rY <br /> ACCEPTED BY: aura <br /> EMPLOYEE#: DATE: / <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: N I PIE: <br /> Fee Amount: f Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />