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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5a oogo 39 <br />OWNER/OPERATOR <br /> <br />. CHECK if <br /> <br />e-1 t9\1- ) 6, el Ai v k BILLING ADDRESS <br />FACILITY NAME --FA c o c q tck <br />(., ON C A-e.. \ I 60 -Iyupo. t,oc <br />SITE ADDRESS <br />\ -2_ \ <br />Street Number <br />S <br />Direction <br />—1*-V1 • <br />Street Name MO cUsk--0 City 9 S -C I <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from SgXress) <br />\ —7 C 0 i k n, -a- '2 Street Number Street Name <br />CITY STATE ZIP qs.-2..4.1z:, <br />PHONE #1 Exr. <br />(2-0 10 :- — ‘sl-D <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR n CHECK if BILLING ADDRESS <br />BUSINESS NAME --r-A (05 0 Co yote y ejl4 -i-1-0 19,1 <br />Puo ,it <br />V b ' i '--tn — ( c73-0 <br />EXT. <br />HOME or MAILING ADDRESS <br />COqtn A-N14- 4 2- <br />FAX # <br />( ) <br />CITY STATE 0/\__ 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 ENVIRONMENTA EALTH DEPARTMENT hourly charges associated with this project Of <br />activity will be billed to me or my business as identified on <br />I also certify that I have prepared this application an <br />COUNTY Ordinance Codes, Standards, STATE and FE <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MA <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />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 provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: C) \),e,Vt 1 GLe I \A)lo,e c,h,,k,-. RECEIVED <br />COMMENTS: <br />JUL 0 1 2019 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: I . IAA 0/1241)0 EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />\ p p EMPLOYEE <br />la <br />#: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: <br />CI° 1 <br />PIA: <br />Fee Amount: \ C7 Z ---- Amount Paid V / 2_ Payment Date ---'7 7 t / i --a) <br />L Payment Type Invoice # Check # l Received By: <br />/ <br />I— / <br />be performed will be done in accordance with all SAN JOAQUIN <br />DATE: <br />OTHER AUTHORIZED AGENT 0 <br />olio I ( t9N <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)