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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNERIOPERATOR LLC(✓ PY'O ey--4n �� t LL-'C. CHECK If BILLING ADDRESS <br /> FA IUTY NAME <br /> ctrM -h)mofi ✓°L <br /> SITE ADDRESS p <br /> Street Number Dlr� city <br /> m m `� ��r� rl <br /> Street me ZI Coae <br /> HOME or MAILING ADDRESS (If Different from Site Address) � Q ��ree(fa C� <br /> - � Street Number StName <br /> CITY _ SLAn STATE ZIP O <br /> 1� Va12 a <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> $ 61 u(V -151 D 130- 030- I'2- <br /> PHONE#2 EXT• BIDS DISTRICT LOC ON CODE <br /> Ctc <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> M ()N 1 cc, Pb t „ CHECK If BILLING ADDRESS, ` <br /> B INESS NAME , l PHONE# EXT. <br /> ern iA3 - 2o21 <br /> HOME Or WILING ADDRESS FAX# <br /> 2 1 p,� I< - ( ) <br /> CITY y„-,t,.1 S cLA4E ZIP -.2- <br /> - (�1 <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 Or <br /> activity will be billed to me or my business as identified on this farm. <br /> 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 /> APPLICANT'S SIGNATURE: `-'DrYkA '46L/(/�❑ [3LI <br /> DATES/: <br /> PROPERTY I BUSINESS OWNEROPERATOR I MANAGER OTHER AUTHORIZED AGENT S D!Siq -N Lila , <br /> If APPLICANT is not the BILLING PARTY Proof of authorization t0 sign IS required Title J <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time it is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMME s: CE�VED <br /> �i y' S,.+2 fly �t s�� / hr <br /> /, scp 15 2017 <br /> 4 VIRONINCOUNTY <br /> C <br /> HEAL r,,LMEN7Al <br /> ACCEPTED BY: c .C� r EMPLOYEE#: DATE!' - r- INT <br /> ASSIGNED TO: EMPLOYEE#: DATE: . - /7 <br /> Date Service Completed (if already completed): SERVICE CODE: -`� PIE: 2' b <br /> Fee Amount: Amount P 30 �� Payment Date /� <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />