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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />--14-01\4a_ /q(zi< <br />FACILITY ID # SERVICE REQUEST # <br />Dos \ 3 1\1/ niDDI LE: <br />OWNER! OPERATOR 1 <br />..... A L .S r CD(:)f <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />1N/7 QPThl L 1:7 -0-cw-k. E_-1)14012-)4 • <br />SITE ADDRESS <br />\ I \ I ..• 4-- 1 Street Number Direction <br />E .Nv\i" ----6,/ Street Name <br />TD ckTi <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Li.(r, 9 CvErt -fic!'-i PL Street Number A Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(C 7'/- 7°S.-- /CD3 S-- <br />AP N tt, <br />-7.1q1 3 i0 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT 2+, LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />A l__II---,--t/D NV/ 4-(-2- 7 l r ,k ETZ__, <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />( Li 1ST <br />PHONE #EXT. <br />((:) CSL-10 — --- S S-- / <br />HOME or MAILING ADDRESS ti CI5 Slio ---v u,-).\-:,-_ Li_ S-f--- • <br />FAX # <br />( ) <br />CITY D 7,6r.N. 1,,-- prrs...4 c i 3 cz, STATE cA • ZIP CH 1 1 c) <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 work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> DATE: 0 I I I <br />PROPERTY / BUSINESS OWNER El" OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <br />If 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 />"Ertivp.tilr TYPE OF SERVICE REQUESTED: Z„i6QuiD viees, i---ic C-44-(::::C.-- Ree ivcco <br />COMMENTS: <br />OCT 22 2019 <br />SAN JOAQU/N li,,, — ..,f' <br />!VAL ' <br />00N-7-, Etvvi <br />fli hEALTH 6-1EpMA i <br />• wil MEN T <br />1 <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />/0 <br />0111 ASSIGNED TO: ri-r <br />EMPLOYEE #: DATE:// <br />Date Service Completed (if alrea y completed): SERVICE CODE: PI E:42_,0 1 <br />Fee Amount: 0 Amount Paid 3014 .---- Payment Date 10 zzfi? <br />Payment Type ot Invoice # Check # l(f (6 g Received By: tWl-nt— <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003