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RECMVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMJ4V 14 2017 <br /> SERVICE REQUEST NIT-A[ HF=AlTk <br /> Type of Business or Property FACILITY ID# 6? <br /> I <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME \Ncsi u Q <br /> �— b <br /> SITE ADDRESS <br /> 2 15 cxrai- 4- 1 ine� 'wail I racy �i 53 <br /> Street Number I Direction Street Na zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Narnc <br /> CITY STATE ZIP <br /> PH0NE#1 EXT. APN# LAND USE APPLICATION 4 <br /> (209) hie 34kA C� ,Dg U 1' <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS N E _ _ PHONE# EXT. <br /> 1 - C <br /> HOME or MAILING ADDRESS FAX# <br /> 1 L,,2 aykob <br /> CITY r STATE Uk ZIP <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,STFAand FEDERAL law � <br /> . <br /> APPLICANT'S SIGNATURE: DATE: f <br /> eQlKr�LcnCQ. <br /> LL <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 13 ® bL5j2feh OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING 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 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 /> TYPE OF SERVIC `i&CSk- c�SPefwl(-s w W i fl$W'i Co nvQ rsjO n Jcya des IS n OM U 17Ct5 . <br /> CONIMENTS: RECEIVED <br /> DEC 0 8 20V <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED EMPLOYEE#: DATE: 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: fd� I <br /> Date Service Completed (if already Completed): SERVICE CODE: (/ P/E: <br /> Fee Amount: Amount Paid LkSG pU Payment Date <br /> Payment Typ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />