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SAN JOAQUIN COUNTY ENVIRONMt;NTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5L46Wa 001 �22� ��`�0�A � ��� <br /> OWNER/OPERATOR 12 <br /> _miriee1.- CHECK If BILLING ADDRESS <br /> FACILITY NAME L �0Yd S l).Io wq <br /> SITE ADDRESS �(10,3t> �E- H`" y $$ (_ocl�e�0Y0) C15�3+ <br /> Street Number Direct lon / Street Name Ctt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) a <br /> 403 5 W Street Number Street Name <br /> CITY Lt,GJL-e -f ok STATE CA_ <br /> ^ ZIP9�3 <br /> PHONE#1 Exi APN# LAND USE APPLICATION# <br /> ( 20�) 50 01 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> K AMV)ee- Vai-o' CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> LOUL e_ Y, s ubw d0j -12-1-3140 <br /> HOME or MAILING ADDRESS 1403S E -Hvix 00 p 9 FAX# <br /> ( ) <br /> CITY j n�1_ T STATE ( n_ ZIP 145 a3-:iL <br /> BILLING ACKNOWwL�EU�DGENIENT: 1, the Undersigned property or business owner, opeei*ator or authorized agent of same. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAI.Ili Df;PARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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,Slctmlar'cts, STATE and FEDtiRAI.,laws. <br /> APPLICANT'S SIGNATURE: v`� % DATE: 05 1`1 <br /> 11Roi,F;RTi,/BCSINESS OWNIERP OPERA'roR/NIANAGEte EIORIZED AGF:N'r❑ 6w V1et{' <br /> IfAPPLICAn'T is not the 131LLIAT;PARTY,pt-oof'of authofizatian to sign is feriuifed Title <br /> AUTHORIZATION TO RELEASE INFORNIATION: When applicable, 1, 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL I-IFALTii DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> NOV 0 5 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Lay ,,,Z_ EMPLOYEE#: ` d j 7 DATE: S <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( P I <br /> Fee Amount: , S 1 Amount Paid S Z_ Payment Date <br /> Payment Type S Invoice# eEk# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />