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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST`# <br /> 5 I P t_ --— — 000-3 H <br /> OWNER/OPERATOR <br /> `'/-5- / /1 ^�t IV ` <br /> FACILITY NAME F CHECK If BILLING ADDRESS <br /> ,Vl//V(1 <br /> SITE ADDRESS �9S F �Zlyu `7'r',4 WQODBR/D4� 11 2.�9 <br /> Street Number Direction Street Name Cit Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 6 . B V Y— 401 Street Number Street Name <br /> CITY /-V D f STATEzip <br /> eA 02'4'1 <br /> PHONE#1 EXT, API# LAND USE APPLICATION# <br /> b� ► 10 — 5- 3 el 5--3*0-60 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> N <br /> r CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH E# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> P. O . 00y, 40q ( ) <br /> CITY D 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 prt�ject specific ENVIRONMENTAL,l�EALTFt DEI'AI2l'.MSN'r 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 certifj that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIiv <br /> COUNT)'Ordinance Codes,Standards,STATE:and FF:DERA1.laws. <br /> APPLICANT'S SIGNATOLEASE <br /> C�, DATE.- IC) � �_ <br /> PROPER'ri,/BusmESSOWNERAT01 /n ANAGER ❑ HFRAOT110RIZEDAGENt❑ <br /> If.1PP111(.,1..VLVG P, t proof of authot tion to sign is required Tule <br /> AUTHORIZATION TO ORN4A ION: 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 anchor environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMFNI AL FIEAL'I'H 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: SGC U K �l O <br /> COMMENTS: \,r0 ,'I ` <br /> X <br /> J V <br /> 2019 <br /> k c�� �4�MFNTU�7-y <br /> ACCEPTED BY: EMPLOYEE#: DATE: e, j <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SER=E CODE: P 1 E:, <br /> Fee Amount: Amount Paid � Payment Date Q 30 <br /> Payment Type DI Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />