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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> VAo02LA � 0b-1°x' 5 <br /> OWNER/OPERATOR v I( > -7I �t 1 n <br /> v�l� CHECK If BILLING ADDRESS <br /> FACILITY NAME G'1'(CGl O is T-7tQ W/ 0 <br /> SITEADDRESS 205 ,11-V 1_ G.�� �\�✓1 - <br /> 1 . Street Name <br /> Street Number Direction � Ci ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Ad esscke) � <br /> 5 1 l V-�ti-- her Street Name <br /> CITY ,�_.a YC. e`A STATE <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (wk) ao3-k,;-k-4 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR V) t - t� <br /> �� CHECK If BILLING ADDRESS El <br /> BUSINESS NAME Chitt on r5 �t \ W/ Ut "TWt S-� PHONE# lBlely— 12\Z. EXT.- <br /> HOME or MAILING ADDRESS FAAXX# <br /> -7 It C�i✓ 1� ( ) <br /> CITY �(,.p 1p( (CA <br /> STATEOA ZIP <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 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. \ `7 <br /> APPLICANT'S SIGNATURE: � /D Q��{ �0�d DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS 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 assessment information <br /> t0 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. y <br /> TYPE OF SERVICE REQUESTED: 1:700dWYE S)A-k � ■��' <br /> COMMENTS: n 1^0vi� OT o .nn n ' ^ '^ IVC® <br /> V V1 Vv Yl�✓ OCT 17 20018 <br /> SAN JOAQUIN COU <br /> HFACTH D NMENTAL TM <br /> ACCEPTED BY; -- t-� EMPLOYEE#: DATE:I <br /> ASSIGNED TO: LM Ae EMPLOYEE#: I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 1 <br /> 1S <br /> Fee Amount: ftl 52- DQ Amount Paid 4' +5� , Payment Date j p11-7119 . <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br /> S <br />