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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 500 S0 LA(P2 <br /> OWNE 4 9PERATOR�/�//' <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1�'y S S�/lC ✓r Street l) ',4 L� I /hS ZrtJ <br /> Str¢el Number Direction Street Name city "121 Catle <br /> HOME Or MAILING ADDRESS (if Different from Site Address) ��St� <br /> Street Numb¢r `/ Stre¢ Name <br /> CITY / NATE ZIP n�� <br /> -o- ;s n V\ a "1 3 <br /> PHAANE#1 APN# LAND USE APPLICATION# <br /> fD0$) .�0�'��3� <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQDESTDR -- D (lvl/�/1�j 'L 1 <br /> ffL(Y�i / ���' <br /> CHECK IfBILLING ADDRESSE] <br /> BUSINESS NAME1( l /y / 1 !' �j�/I PHO E# EZT. <br /> �CJr i 14 3D - �"7 3�3 <br /> HOME or DDR FAX# <br /> CITY f-f��'Gi STA re /1 ZIP <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 /> 1 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. A /� <br /> APPLICANT'S SIGNATURE: DATE: to L'[" <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICAN s of the BILLING PARTY,proof of authorization to sign is 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it Is providGd,t� @rNT <br /> my representative. 1"AT 11116 <br /> TYPE OF SERVICE REQUESTED: <br /> q&;CLQ m ED <br /> COMMENTS: APR 12 2019 <br /> SAN JOAQUIN COUNTY <br /> ENViRONME NITAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service COmple ed (if already co pleted): SERVICE CODE: 00 /E: Q <br /> Fee Amount: lCJ'L_ Amount Paid /lj' — Payment Date rZ l <br /> Payment Type ✓ 2 1 <br /> Invoice# (Check# Z V I Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />