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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID <br /> SERVICE REQUEST# <br /> F , � <br /> LT 18 n 22. (, y 00 geC L-1 <br /> OWNER/OPERATOR f T <br /> EL/7E C(; 7o- j D m 4% L(— C, CMLspf if]}1LUNG ADOR£SS <br /> FACI'JTY NAME r-�—Cs <br /> SITE ADDRESS <br /> IFl/ ►J• C�Je +� s-7o�uC C'o�RT �7ouc7o►.1 95 z12 <br /> Stmet Numbor Dirso' W"" <br /> ctly zip Co <br /> de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) r f d.,,C. ?,_1 l <br /> Strnet Numb,- Street N me <br /> CITY ST t5 L K-7c hf STATE zip _ <br /> PHONE#1 W. <br /> :5 213_T53 C/ ,1 LAND USE APPUCAnON t <br /> PHONE xz ltrt. 2 C <br /> BOS DtsTRI T;^y� IpQA <br /> CONTRACTOR / SERVICE REQUESTOR <br /> FREUESTORIL, FZj S C#s{ CHECK M BILLING ADDRESSINESS NAME J�I r �r L� � PHCa1E,� `-><*. <br /> Hom-_or MAIUNG ADDRESS Fax <br /> CITY 5_r0C_47t,1J STATE ZIP <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 HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 JOAQt 1", <br /> COUNTY Ordinance Codes,StandardS,STATE and 7T� <br /> APPLICANTS SIGNATURE: 1 r D 20/ 9 <br /> DATE: <br /> PROPERTY/BUSt?dYSs OK'1t:R PF3L;TOK/. A�ACER ❑ OTHER Au'i'ttORtzEDACt�wr❑_ <br /> IjAPPLJCANT is not the AUILA'G/ARTY.Proof of authorization to sign is required I Tlrte <br /> AU FHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property locate"the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sne assessment <br /> LAP <br /> infnrrnation to the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> ERVICE REQUESTED: 1714,, <br /> PAY C-�I �t�C�� S �r_-rC T) 6C 6� K�1 C REC <br /> ,4 1 Q 2019 NVIRONMENTAL HEAL <br /> uIN Ct7UN7y PERMIT/SERVICES <br /> BHN d0 AL <br /> EPN1 �e <br /> OF-ALT Lr EMPLOYEE#: L: I DATE: <br /> ASSIGNED TO: EMPLOYEE�: g DATE: <br /> Date Service Compl ed (it 1 dy co letod): SERVICEOCODE: - 2-7z PfE:V i <br /> Fee Amount: ' - 1 <br /> Amount Pa 3 (�� Payment Date r0 <br /> Payment Type Invoice# Cheek# I Receive By: <br /> EN_:45-c�-czs <br /> REV-SED 11117,2003 SR FORM(Gokfen Rod) <br />