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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-Ylioco Mary& ::1s�00�i 32 <br /> OWNERI OPERAT R <br /> ) 1 CHECK If BILLING ADDRESS <br /> FAcI NAM <br /> O C ry) 1 <br /> SITE ADDRESS Iq O <br /> t� S SchL:�-I-n- C Trczc- 953r1r7 <br /> Street Numbar Direction Street Name CI ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) `( _ 4#0 e ,Ulu <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> � t / <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> fA l Sag- 61; � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REo sro _ <br /> o —17 —7—ra ck rn 'Z(a P rxm CHECK If BILLING ADDRESS <br /> BUS NESS NAME �� PHOS# c EXT. <br /> LrlawI <br /> HOME or I G ADDRESS FAX# o <br /> CACC ( ) <br /> CITY I ,e _ STA G ZIP , <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 ENvnzomMENTAL 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,STATTI Wd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: P *4- / — DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT I -QCrL- I/ <br /> /f APPLICANT i5 not the BILLING PARTY proof Of authorization to sign is required Title a <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: ; T ' FN <br /> COMMENTS: CD <br /> NOV 2? <br /> 2019 <br /> SENM�T) <br /> ACCEPTED BY: EMPLOYEE M DATE: I( .LO <br /> ASSIGNEDTO: , 1,tAEMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIE: I Wu <br /> Fee Amount: I �'1 , Amount Pai / e2 Payment Date 111 / <br /> Payment Type Invoice# Check# ��93DZ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ^ O �,[�� <br />