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SAN JOAQUIRCOUNTY ENVIRONMENTAL HEALTH DLPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> La <br /> o 1 5 �(eq S OM2-qq <br /> OWNER/OPERATOR <br /> Mar. �(� <br /> \�fa \ - CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> FOY\ ;-i"tclr•SITE ADDRESS ( „IQ <br /> fm C GrQ� -n'tT� s I 'L— O a I <br /> Street NuuJmber Direction S get Name city Zi Code <br /> HOME Or MAILING ADDR S (If Different fr Site Address <br /> \ K 1- Street Number C1 ` Street NameO <br /> CITY STATE ZIP 61 52,0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# "` <br /> (7-" '}5Z- U2,(Q \ <br /> PHONE#2 ExT. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMEU& 1 - <br /> PHONE# ExT' <br /> HOME Or MAILING ADDRESS FAz# <br /> CITY STATE ZIP q g225 <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 assoclated with this project or <br /> 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 /> APPLICANT'S SIGNATURE: KAaY-f-i-, C _ DATE: O r ) I OCj U I L 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGERS OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY,proof Of authorization to sign IS required Title <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 assesff <br /> rq�ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same tlmeI Ona Or <br /> my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: MAR 0 6 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ,M/� �7.� HEALTH DEPARTMENT <br /> ACCEPTED BY: (A / d EMPLOYEE#: ice/ ) DATE: -3169 <br /> i <br /> ASSIGNED TO: Ge ��//ll EMPLOYEE#: !/ /\\ DATE: :;3A;1 <br /> (Y / <br /> Date Service Completed (If already Completed): SERVICE CODE: V /Q PIE' O <br /> Fee Amount: i 2'd) Amount Paid 5 2 PaymentDate <br /> "70 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />