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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7 C� lv)K <br /> OWNER/OP TOR <br /> �A�rnn IAS `C( CHECK If BILLING ADDRESS <br /> /r"l i�- L,.it•/� I <br /> FACILITY NAME <br /> CA L► Fo iZA�>t�,4 L�LL�L i,c r LL—C: <br /> SITE ADDRESS S (L .� Na 5 DG -75-)-Os <br /> � ISOStreet Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT 77CATIONOCODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C�Au FOR.4)i�4 6c5wt,► t)cs, L..i_.L S >; ►"7 5O <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 1 G`GK-1 a STATE ZIP 4 S'ZG <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 <br /> or 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. <br /> APPLICANT'S SIGNATURE: 4ytk,d -!S" S L� DATE: AW 2 7 .20 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /fAPPL/CANT 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 <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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAY <br /> TYPE OF SERVICE REQUESTED: s'C 6 1 ECEIV <br /> COMMENTS: <br /> 2019 <br /> SAN JOAQUIN COU <br /> T'q�RONMENT'HEF <br /> DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ®Z <br /> Fee Amount: l Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />