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AMIQ A Ar TI -1 A niTIN i"111TN'fTV F.Nv'IRONMENTAL HEAL <br />�.�. <br />SERVICE REQUEST <br />EXPIRED "- :PJRI <br />Type of Business or Property <br />FACILITY ID # <br />C,S�ERVICE REQUEST # <br />ADDRESS ❑ <br />OWNER / OPERATOR <br />j,m <br />Ad s IAS <br />CHECK if BILLING <br />FACILITY NAME <br />SITE ADDRESS,I"LI(�pt?e <br />Rd. �c,,Q✓►- C�rorl 95� gP <br />Street Number Direction <br />4 wtrbet Name <br />CI 71 Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Nama <br />STATE Zip <br />CITY <br />PHONE #1 ExT. <br />AP;�J <br />LAND USE APPLICATION # <br />r7 <br />Uu ()o - <br />PHONE #1T <br />BOS DISTRI1CT LOCATION CODE <br />Oc Li <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ^ i �6 r f - !D <br />BUSINESS NAMEA <br />CHECK if BILLING ADDRESS <br />PH NE # EXT.17 r7 o <br />-- - -I FAx# <br />HOME or MAILING ADDRESSi ( <br />(� � (.� STATE �., ZIP <br />C <br />D !v <br />I...j Tovil G ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent o11-0 f same, <br />edge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />will be billed to me or my business as identified on this form. <br />I ft certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />WOrdinance Codes, Standards, STATE and FEDERAL laws. <br />AMICANT'S SIGNATURE: / DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Title <br />If APPLrCAYT is not the BILLING P,1nTY 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. r.% ^ r= mA nr= r---. <br />TYPE OF SERVICE REQUESTED: C G (\ SU I � U k, Q n U NN <br />IL— <br />COMMENTS: `c PENT APR 0 4 2018 <br />'ENVIRONMENTAL HEALTH <br />EXPIRED PERMIT/SERVICES <br />ACCEPTED BY: r S S <br />ASSIGNED TO: S h <br />Date Service Completed (if already completed): <br />Fee Amount: S 1 <br />Payment Type v A <br />EHO 48-02-025 <br />REVISED 11/17/2003 <br />invoice # <br />Amount Paid <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: 6 6 I <br />s Payment Date <br />Check # 2015 <br />DATE: Li ' LI - I <br />DATE: U . 6.' I f <br />PIE: Iva o2 <br />Received By: <br />SR FORM (Golden Rod) <br />