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SAN JOAQUIN Iv _ JNTY ENVIRONMENTAL HEALTH ARTMENT <br />SERVICE REQUEST <br />Type Of Business or Property <br />CHECK if BILLING ADDRESS Er <br />BUSINESS NA p�I WW1. �O�L C (k I�1 e <br />l <br />FACILITY ID # <br />SERVICE REQUEST # <br />Vt� <br />ACCEPTED BY: / Q <br />1 <br />(y/�I��-( <br />z <br />-7 <br />Kao 1155 <br />OWNER I OPERA <br />7xidlle. <br />c(c, <br />CHECK If BILLING ADDRESS❑ <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 5;�7j <br />FACILITY NAME <br />CCAU�-: <br />I,SI—ri7 <br />Lf�//zl4 <br />PSTOGl <br />SITE DR SSs <br />`V -v` <br />/%(�P <br />U�'ql <br />Payment Type V lSti <br />Invoice# <br />L� <br />/ <br />�� <br />t7� `� Street Number <br />Dlrec[lon <br />"\StmetN <br />me <br />Cit <br />C. <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />/I ✓ e, 5.0 O <br />vv <br />Zo <br />/Street <br />5C) <br />L� <br />Street Number l <br />Name <br />CITY <br />STATE <br />ZIP 9��a5 <br />QC <br />P EXT. <br />APN # <br />LAND USE APPLICATION # <br />EXT• <br />BOB DMISTR�ICT <br />W <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR AWeC� Y`� ` <br />IIV l [ <br />CHECK if BILLING ADDRESS Er <br />BUSINESS NA p�I WW1. �O�L C (k I�1 e <br />l <br />COMMENTS: <br />PNSIt!/�# 171? 7-6 EX <br />HOME or MAILING AITSS <br />ACCEPTED BY: / Q <br />1 <br />(y/�I��-( <br />z <br />CITY P1'LI },'41,t:. 4q, 4�3STATE <br />CA- ZIP <br />�� <br />BILLING ACKNOWLEDGEMENT: 1, 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 <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 pe ormed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S/ TE and FEDIIE� AL laws. G <br />APPLICANT'S SIGNATURE: // it G DATE: / 126 P9 <br />PROPERTY /BUSMESSOWNER❑ OPEIL\TOR/iVIANAGER❑ OTNERAUTHORIZED AGENLfTt%Y12,4[XTOt2 <br />/f APPLICANT is not the BILLING PARTY proof of authoriZation to sign is required 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: CEM <br />Ail P1217 C/U94 <br />AA <br />COMMENTS: <br />RECEIVED <br />SEP 13 2019 <br />NJOASAN <br />l/Pn11."�N�COUNT <br />ACCEPTED BY: / Q <br />1 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />2 <br />EMPLOYEE #: <br />DATE: 9 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 5;�7j <br />P1 E: JJ✓(eo a-' <br />Fee Amount: <br />im <br />Amount Paid <br />--1 V <br />Payment Date <br />VI <br />Payment Type V lSti <br />Invoice# <br />Check# µ9G ? 27c13/ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />