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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4W A - tVE 2� p 0 S I I S2- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME l ,,f,e� ��� �IV�✓��`��� '/ <br /> SITE ADDRESS <br /> �J j � L '�^ <br /> Street Number Aion �OJ Street�T' �a e — ' I Cit V) �i✓Cod(ee <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ^'1 0 15 i Street Number Street Name <br /> CITY 1� STATE ZIP <br /> PHONE#1 b EXT. __[APN# LAND USE APPLICATION# 7 <br /> (6�) So (f �Od 13 3°I-aA q <br /> PHONE#2 EXT. BOSISTRI T LOCATION CODE <br /> ( ) O� C I <br /> CO TRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 1 _e V,Y,�� CHECK If BILLING ADDRESS <br /> BUSINESS NAMEV � 1 PH9N �Q of �7 <br /> p2s <br /> HOME Or MAILING ADDRESS I FAx# / <br /> �(D5 NCo M L✓c-e ST , ( ) <br /> CITY SIM L 4 <br /> v\ STATE `-' I ZIP 43520 <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 EN VIR L HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as ides Ified on thi form. <br /> I also certify that I have prepared this application a that th ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA E al d F-DER laws. q <br /> APPLICANT'S SIGNATURE: ,_,,/ DATE: / -13 - 2,P <br /> PROPERTY/BUSINESSOWNERL3 OPERATOR/MANAGER L] OTHER AUTHORIZED AGENT <br /> If APPLICANT is mol the I31LLLN'G PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 COUN"IY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: '� l GO Ins Lo in', n <br /> COMMENTS: <br /> SEP 13 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ?-Q_( Mzo EMPLOYEE M DATE: <br /> ASSIGNLD TO: F l 6>ir v- v&z EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: `�O <br /> Fee Amount: )i CD_ Amount Paid / 5 2 Payment Date <br /> Payment Type Invoice# Check# C ( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />