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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHO <br />DATE: <br />ED AGENT 0 <br /> <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Pr perty FACILITY ID # SERVICE REQUEST # <br />0ig6 00 <br />21.0ER / OPERATOR <br />-t-4CAlliC-A. V1/4LC:C14 "-114 CHECK if BILLING ADDRESS El <br />FACILITY NAME <br />SITE ADDRESS <br />2-43 Street Number Direction kV -.1AA-4 "4"iitreet Name f•-•L R -Ac...41 6 <br />9...c2-2n <br />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 <br />( ) <br />Ex-r. BOS DISTRICT <br />9 <br />LOCATION CODE <br />6/ CI <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTS:1E1 <br />t 1-Vr114. vaLii,,,....t-ve_y <br />— <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />(2t.`b <br />EXT. <br />ci(o -2-4C3 <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY <br />I\ e—k-1144e STAT(Ak . ZIP 9....--z2c) <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 <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 we k to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards ATE and FEDERAL la s. <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 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: Ve r cii iot.,,, fio r, tics ep i; 1 51/1/54e kel <br />COMMENTS: Ve f k Cy thci-i. 'pet.) pool - vsi i I I wipe f Se tba (,is io r(1f1.5 hilffitnik Are )41 <br />1 CALL (209) 953-7697 0 r (ale . 'I. etElve407. FOR INSPECTION, <br />APR 0 1 48 HOUR NOTICE <br />C 2021 REQUIRED. SAN Jo <br />ACCEPTED BY:/....-4/._..- jig,,,,ENVIA0QA,Li1A1 CO 7.„, Em P LO T Lryrien,Paivpilif4riltily t r DATE: 9 /aid 1 <br />ASSIGNED To: FR Al?7-MENT EMPLOYEE #: DATE: Via iid i <br />Date Service Completed Of already completed): SERVICE CODE: 0 i <br />Payment Date <br />I PIE: Lidoo <br />41001 <br />Received By: <br />/ <br />Fee Amount: 4" ).--c? Amount Paid <br />Payment Type 'tit a Invoice # Check # <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)