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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUTTY IID## AP <br /> RV1157'):,$tT,#t <br /> r O O I"J�'C ,4L�"4 <br /> OWNER/OPERATOR <br /> LJIt, CHECK If BILLING ADDRESS <br /> FACILITY NAME (1 <br /> S IAD\ �l4io5c .•,e tc�nesut dock hx� `�50�� <br /> Street Number I Dimcdon Stroet Name C I C e <br /> HOME or MAILING ADDRESS l ferent from Site Address) �6CVAK C.aW(A- <br /> �,.J StmtNu ber st�et INS. <br /> CITY , STATE (frk zip q.53(0(0 <br /> � <br /> PHOEin OCT. APN# LAND USE APPLICATION# <br /> (dL'i) LIU, - p PAY 1VT <br /> PHONEY ET. BOS DISTRICT LOCATION ' �D <br /> CONTRACTOR/ SERVICE REQUESTOR 7 2020 <br /> REQUESTOR \ AQ <br /> U cHEC/CNBIL (JN Ty <br /> f�TVkM � y� NAL <br /> BUSINESS NAME - PHONE# �T ENT <br /> V Wvrc, g �Z. CISZ <br /> HOMEOrLING ADDRESS FAX# <br /> 6 uut/l� ( ) <br /> CITY d STATE C44„. zip Cts <br /> RTLi•IN . ACKNO • .DG . .NT: 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,Sym anF <br /> APPLICANT'S SIGNATURE: DATE: 511<3 C7 <br /> PROPERTY/BUSINEss OWNERO OPERATOR/MANAGER D OTHER AUTHORIZED AGENT O <br /> I,fAPPLICANT 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 and at same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: "r P b d tAI (A tl S u.Ct�im IA 21 <br /> 1 1 <br /> 0.5U C� o t,t..-i L6 o K A co � 1916 tA I'A;m n n@ s N R Quin/ ?020 <br /> -�P 83-b f COIJIV <br /> � 142 ?)-5.9 6 g k'OD' Corr) HEgLTH p pq lME1VT <br /> ACCEPTED BY: EMPLOYEE M <7 <br /> DATE: /S 20 <br /> ASSIGNED TO: �1 EMPLOYEE#: DATE: 15 9 <br /> Date Service Completed (N already completed): SERVICE CODE: P E:: D <br /> Fee Amcun • 5 ' UU Amount Pal /,l,6>Z)43o Payment Date u <br /> Payment Type ;5; Invoice# Check# r�g�� J Received By: <br /> ` <br /> EHD 48-02-025 t"6 _'1 SR FORM(Golden Rod) <br /> REVISED 11/17/20033ny-v� �/ <br />