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SAN JOAQt ;OUN Y ENVIRONMENTAL REALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACWTY ID# SERVICE REQUEST# <br /> Trnf)er GjiCD0�0Iq <br /> OWNER/OPERATOR <br /> des o2 0 Ceaj^ CNECKNBRuasaoo <br /> FAcnmNANE EI -M�0 <br /> WEADDRESS 5I ►-� y �� 2�� S1 or,IGh�✓� '15-2 2 <br /> Saeet Numoer <br /> traction Street Name L Code <br /> HONE orMNmADDRESS (if oweremfromSite Address) C51 b0 Hqq spy 2A Li <br /> Snaet Ianed>ar Street Name <br /> CITY �]n.n t/.Fay... STATE n ^ ZIP <br /> PHONE#1 _��tt��l/1" 1'-'y ' Exr- APN LAND USE`(JAPat tcA` MON# <br /> (Sig-2) ZL4(9 -b260 <br /> PtrotrFiR E" BOSDIsracT LocAnONCODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR L'n <br /> cz.W 0 (?Q(Z Aj OFMCKif8wNCADtxtEss <br /> BUSINESS NAME q' � (;MCA �,tC/` _ �C J ^ �cr, <br /> HomEorMAWNeADDRESS !, l � FAX# <br /> SI0D <br /> Cry 510W--+:4A <br /> STATE /1A ZIP 015-? t Z <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized aage`nIt 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /A�06T.�L, O DATE: 2"p-14) <br /> PROPERTY/BUSINESS0wNW2r OPEPATOR/MANAGE11 OTNERAMoRmWAGENT❑ <br /> IfAPPLIC41✓T is not the BJLLING PAliar,proof of audioription 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 JOAQUtN COUNTY ENVIRONMENTAL HEALTTt DEPARTMENT as soon as it is py�J�jy,�ud ett6e same time it is <br /> provided to me or my representative. P 7 EYiC1V <br /> ED <br /> TYRE of SERVICE REQI,ESrm 1 G n !Zt V f W ' DG1 T r <br /> Wim' FEB 0 8 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> AccEPTEOBr: \ . W EetPLOYEEtk DATE: 1 <br /> ASSIGNEE V EmPLOYEE#: DATe -Z_ ��OI <br /> Date Service Completed (if already comp ): SERVICE CODE: C�2 <br /> Fee Amouo3 Amount Paid ��56 r) Payment Data 2, 19 <br /> Payment Type I d Invoice# Check#EHID Recehred By: <br /> REV 4ED 1111 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />