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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> hQWV- e-VCb79�T <br /> OWNER I OPERATO <br /> O GS, <br /> I� CHECK 11 BILLING ADDRESS <br /> FACILITY NAME T <br /> NAYnYyIC✓ j OY / ) <br /> SITE ADDRESS 1031 West L5'hG S 6c F Tor q6-7-10 <br /> U Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sir¢¢t Name <br /> CITY STATE ZIP <br /> PHONE#1 E%T. APN# LAND USE APPLICATION# <br /> (g2S-) 15Z- OW6- n$ 6 )S`0 r5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I ) pOH co <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR G I- /�1 <br /> an �� ""`(/' CHECK IS BILLING ADDRES <br /> BUSINESS NAME uu�� PHONE# Ems' <br /> fl !11 Gr Li or IS2—�/PP <br /> HOME Or MAILING ADDRESS FAX# <br /> o c nAt1A I ) <br /> CITY rIfTA r STATE ZIP fq 7q <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 /> 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: �l 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. <br /> TYPE OF SERVICE REQUESTED: b Or' R <br /> COMMENTS: St` 2018 <br /> � 0 <br /> c� aw✓l9� <br /> CSA.✓L� SAN JOAQUIN C <br /> EAMRON)WS11&kt'64 PART E OUNTy <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: G L t I PI E: <br /> Fee Amount: CJ 2 Amount Paid 1 SZ — Payment Date q J7 <br /> Payment Type�� t— Invoice# Check# Received By: <br /> f g 2••S S 11 97q <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 IS <br />