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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTH DEPARTMENT <br /> V <br /> SERVICE REQUEST <br /> Type of Busine or Property FACILITY ID# SERVICE REQUEST# <br /> -A-- 1,( . : :1 1-`r-7 3 <br /> OWNER/OPERATOR - <br /> CHECK If BILLING ADDRESS i <br /> O <br /> FACILITY NAME <br /> r a,, �t <br /> SITE ADDRESS� ���I �S �G•�A� <br /> 8t/ Street Number Direction Street Nnme n Cit—+ i lode <br /> HOME nr MAILING ADDRESS,fIf Different from Site Address) SDt/ <br /> Street Number stmet Name <br /> Cl.T t 1 STATE <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> I /v 16 Z 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO / - <br /> CHECK if BILLING AODREa <br /> l <br /> BUSINESS NAME PHONE# Ext• <br /> 4 �nit _JGrY/CGS 0 1 C d lJ <br /> HOME Cr MAILINrADDRESS - J FAx# <br /> I ) <br /> CITY 17 STArw ZIP alrj( I <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 ENVIRONMENTAL HCAvrii DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with nit SAN JOAQUIN <br /> COUNTY Ordinance Codes,,S'/nndai•r • " 're and F iDP) I s. <br /> I <br /> APPLICANT'S SIGNATURE: l DATE: <br /> PROPERTY/BUSINESSOWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT. GTI{ <br /> JfAIVILICAArisnot the BILLING PAR proof of authorization to sign is required Titiell <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 e0ironmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at t''l$4/WIp@ time it is <br /> provided to me or my representative. /r11 y�"��1�'• iii <br /> TYPE OF SERVICE REQUESTED: 1VE <br /> COMMENTS: 9 2019 <br /> -SAN 1hQAQU1 <br /> FAITH pEPA IV M NT <br /> TY <br /> ACCEPTED BY: —C"Z"(-r, a Sc--o EMPLOYEE If: DATE: <br /> ASSIGNED TO: µV'cjw("K 9 EMPLOYEE III: DATE: 67 — / I <br /> Date Service Completed (N already completed): SERVICE CODE: S 23 P1 E: (0O <br /> Fee Amount: Amount Pai 1/<—J. <br /> Od Payment Date <br /> Payment Type ul Invoice# Check# /061 Ig S" Recei ed 8y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712DO3 <br /> P' 5212 $�l S <br />