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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business r Property FACILITY ID# SERVICE REQUEST# <br /> 9M S17k �26a�1� <br /> OWNER/OPERATO� 2� <br /> 17 <br /> CHECK If BILLING ADDRESS <br /> OCT 10FACILITY NAME /_W� �-V ENVIRONMENTAL HEALTH <br /> FIEFRINITISERVIPER <br /> �j <br /> SIC�fAPDRESS $ t/�kca' f� zr 9�Q`7 <br /> L �� Street Number Direction V Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) ODD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMELI/' 19���.�s PHON n ,2--S-Z67 EXT. <br /> HOME Or MAILING ADDRESS7 ( , FAIL)Vq'[—t-2 3 <br /> CITYC, STATE ZIP 9?^7/za <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorizedagent 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,STATE ws. <br /> APPLICANT'S SIGNATURE: DATE: / v/; <br /> 4 / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT G� <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is require 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. <br /> TYPE OF SERVICE REQUESTED: I . AYMEjV <br /> COMMENTS: a CEIVE[) <br /> E[) <br /> JUL 2 0 2018 <br /> SAN JOAQUIN COUNTY <br /> H <br /> ENVIRONMENTAL <br /> HEALTH <br /> DEPq <br /> ACCEPTED BY: (yb N6to EMPLOYEE#: DATE: O• L(1 . �a-- <br /> ASSIGNED TO: ' "Q G��x `vv, r EMPLOYEE#: olbOk <br /> 4 DATE: 1 O Vb 1 — <br /> Date Service Completed (if already completed): SERVICE CODE: l PIE: d3 <br /> Fee Amount: 3 p d Amount Paid 4t2`t'a� -,:2� , Payment Date —71,20 t, <br /> Payment Type Invoice# Check# �vd GJ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />