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RECEIVEAMMID <br /> NOV 2 6 2018 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT !�,NVIRONMENTAL HEALTH <br /> SERVICE REQUEST nEPARTMENT <br /> Type of Rosiness or Property FACII I IY ID tf SERVICE REQUEST k <br /> lrlc•LuIII ILII luntilCnll,lilli11nlInt';If, 60 Q f/ <br /> OWNER 1 OPERATOR <br /> SII'! clI, 1'I 1II/"N Itl'tilVl'titi Csei,xUBILLING ADoacss❑ <br /> FACILIry NAME 1 Vii/mi Biisincv,- 1111KCA <br /> __T <br /> f SrrEAooncss ;00 11 %V lllrnrr itll:ul l,�nf (1'tl•t7 <br /> Slrf�1 NumC._.t,.•1_Q <br /> HOME or MAILING ADDRESS (If Dlfforont from Slta Addrai (}rult;( ti I <br /> Mall I!!LTI <br /> CITM ilitrtllilllltyt(1(1 STATE (.A ZIP o2{11, <br /> P., APN M LAII USF APPLICATION M <br /> I I <br /> PHONE M2 E" 9D5 DISTRICT LOCATION COOL <br /> ( I <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> V:tncstia 0 C1 c};q CNEG14 if PILLING AODflE 55© <br /> BUSINESS NAME Sullwesi iingincering(,(Inst ruiLaors, hic Pggg ev <br /> _ g8-873'7 <br /> HOME or MAILING ADDRESS 4780Cheyentiv Way FAx9 <br /> CIT( Chillo STATE (::1 ZIP 91710 <br /> BILLING ACKNOWLEDGEMENT. 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this pro}ect or <br /> activity will be billed to me or my business as identified on this farm <br /> 1 also certify that 1 have prepared thl6 a pl$Ca111 end Iha1 he work to be performed wit be done In accordance unlh all SAN JOAQUIN <br /> CouvTY Qr�iinsnca Codes, Slandards_ 'ATE arl >EDERAI. ws. <br /> APPLICANT'$SIGNATURE: ` 6 'A I - DATE:_ T} <br /> PROPERTY l9119INEe5OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZEDAGENT ® iIrC11CCl Manager <br /> if APPLICANT is <br /> not the 81f oyo PAR proof Of authcllzatfon to sign 14 required Tll1 e <br /> AU_THORgATION TO$C,LEASE 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 andlor environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMEN7Ai.HEALTH DEPARTMENT as soon as It Is available and at the same time It is provided to am or <br /> my representalive. <br /> TYPE OFSERVicEREQUESTED: FLIA) Inslallalion -44 av <br /> COMMENTS: <br /> 2018 <br /> ;SAN <br /> U1IV <br /> HE4C VfROM COUN71, <br /> ACCEPTED Ely: D,-1 y�C ��h art .-, EMPLOYEE 0: C l - r DAh: � -,A 17 <br /> , <br /> ASSIGNEI]TO: VltCf/� '\ 1 1 �1 C"�' EMPLOYEE A: DA1E: <br /> Date Service Completed ( already complatad); SERVICE CODE: 1 fq�y P f E: ' ',C <br /> Fee Amount: Amount Pald 7 Payment Data 1 r /-2 1 <br /> Payment Type krvo1�118 <br /> hock d Received BY: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> 07117/08 <br /> Handy Scanner for Android <br />