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SAN JOAQUIN %,OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE bDREQUEST <br /> F u�I x/53 gr, 77 q7;L <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME -` VAL%t7—t y)0� Ca+er' <br /> SITEADDRESS 1 ' 1`�_uI S.�.Os1/ �� <br /> Street Number Directlon td� Street Name cl Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Szlrnber Street Name <br /> CITY STATE ZIP 7�v <br /> PHONE#t TVA' Ems' APN# LAND USE APPLICATION# <br /> (Zo)) 6�'i_ q� <br /> PHONE#2 EXT. BOS DISTRICT LOCATIONODE <br /> ( ) 0>G� 9� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1.,Ac/v\;I Km Ds CHECK If BILLING AD DIES <br /> BUSINESS NAME1�"� -0j 0, '(� P'[ /'1U� iy l^� /�/,te/y'I^ P NEIt -to y EXT. <br /> HOME or MAILING ADDRESS 1Jp�JJ' Vt' l l�✓1,1" 1 L FAX <br /> L ( ) <br /> CITY a y STAT 9--- zip C45ZO <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 /> APPLICANT'S SIGNATURE: Qfa= ATE; <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICATISn the BILLING PARTY,proof Of authorization t0 Sign i5 required - 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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: � � VPyI(C�-2.. C7C3y1 PAYPAPNT <br /> COMMENTS: RECEIVED' <br /> APR U 5 2018 <br /> SAN JOAQUIN COUNTY, <br /> ENVIRONMENTAL. <br /> ACCEPTED BY: EMPLOYEE <br /> ASSIGNED TO: .•�C_L�..l EMPLOYEE#: DATE: q- cam- /CY <br /> Date Service Completed (if already completed): SERVICE CODE: r, /PIE: <br /> Fee Amount: I C70:2-- Amount Paid 5-,;!, — Payment Date -1 _ S , <br /> Payment Type ip e6'I } Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> 07/17/08 <br />