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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> nlev3 S 853 <br /> OWNERIOPERATORI I <br /> L- 1124 <br /> I ► � LIZ A v rn Z' CHECK If BILLING ADDRESS <br /> FACILITY NAME lJ _ n <br /> SITE ADDRESS ` ' N t�� I� <br /> stre¢t Number Direction u 1 V cant t Nam T 1 hCl ! ZI Cotle SCJ <br /> HOME Or MAILING ADDRESS (If Brentfr mSite Address) PaGCI ` (& A�.� <br /> Street Number Street Name <br /> CITY r^ ` ( STATE ^ ZIP <br /> PH NE#t VGill E' . APN# PBO <br /> D USE APLPLLIICATION# lNL <br /> (�� tau- ass► ► aur► <br /> PHONE#2 EXT. S DISTRICT LOCATION CODE <br /> ( ) b(7 C� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C l L z I-I ev-na v� e z CHECK If BILLING ADDRESS✓ <br /> EXT. <br /> BUSINESS NAME Cone- ��� -,� Py E# <br /> HOME Or MAILING ADDRESS FAX# <br /> N - P c, A Ve ( > <br /> CIN STATE �f/V ZIP n <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 /> 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 /> APPLICANT'S SIGNATURE: DATE: dLJ <br /> PROPERTY I BUSINESS OWNER- OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY proof Of authorization to sign is require(/ 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: G si kk a Ri #Ak�f r X U <br /> COMMENTS: <br /> JUN 2 9 2017 <br /> SAM JOAGUIN COU <br /> EANI '6NMENTN� <br /> l'EALTbf OEjA Nrg' r <br /> ACCEPTED BY: --�,-,�{ �jl EMPLOYEE#: DATE: <br /> ASSIGNED TO: ✓l.��yc`1 EMPLOYEE#: DATE: <br /> 0.0 <br /> Date Service Completed (if already completed): SERVICE CODE ��� P I E: , <br /> Fee Amount: 13 / Amount Paid 31700 Payment Date w -)-q` <br /> Payment Type Invoice It Chad# C 1� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />