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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />�7Vl 15-Q- <br />A OV tosSG <br />aDS] Ll6S <br />OWNER/OPERATOR J Cru RTMb&p �1�CAK fbftlw6 CHECK It BILLING ADDRESS <br />� <br />/� 1' r� r <br />FACILITY NAME C L C 1A � to 'T s' C_ c L) N I R ,Q K G I <br />Y w A <br />SITE ADDRESS <br />F, <br />H 1 01H IAA ftY $ 9 <br />C Z—M(--lu TS <br />q S ° A -J <br />'OR 3 0 Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (if Different fromSite Address) <br />DATE: Imo)L <br />10 11 t , �ii OV -01, Q AI`nitrV Y Street Number <br />Street Name <br />CITY STATE ZIP <br />Sort o VCk- q s 3 Y) <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />I � o 9) k 5-L4 ^ $ $ <br />leted): <br />SERVICE CODE: 040 <br />PHONE #2 —�— Eau. <br />BOS DISTRICT <br />LOCATION CODE <br />(9-08- I - k \3 <br />Payment Date �2 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR SuRtntp£9, cST,y(ft K Q)A--,) CHECK If BILLING ADDRESS Ir <br />BUSINESS NAME C L �. M &M TS CoUKITRY M fvp K E T <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />\o '1 I, — f?:) U <br />FAX# <br />I I ) <br />CITY Ci __ O✓ STAT ZIP C? 3 <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 <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and that he work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, A and CEDE L laws. <br />r <br />APPLICANT'S SIGNATURE: DATE: - 0,2'. AOI l <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT <br />ffAPPL/CANT 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 <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 the Same time it is <br />provided to me or my representative. PAVxapp . <br />TYPE OF SERVICE REQUESTED: —J�D i) <br />Cti1�tS WV <br />EC <br />COMMENTS: ^ O <br />DEC 0 3 <br />2019 <br />ACCEPTED BY: <br />UY V <br />EMPLOYEE M - <br />DATE: Imo)L <br />1 <br />1 <br />ASSIGNED TO: <br />r\ <br />EMPLOYEE M <br />DATE: <br />Date Service Comp eted (If already com <br />leted): <br />SERVICE CODE: 040 <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date �2 <br />Payment TypeInvoice <br /># Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />