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SAN JOAQUTA COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' C- <br /> OWNER/OPERATOR <br /> z,,,„J d/' •_4 U / G CHECK If BILLING ADDRESS E] <br /> FACILITY NAME / <br /> ,AZ ��, S Yx4eeAh uI �cLlc � <br /> U <br /> L< n Z pSITE ADDRESS a 3 <br /> Street Number Direction Street Name J City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �7 <br /> 2U, UJ 6k-.S K 1 r1 'k1 5 Street Number Street Name <br /> CITY STATE Z/IP� /J <br /> PHONE#1 EXT. --[APN# LAND USE APPLICATION# <br /> (Z ceA 3cI o ' 2(c <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Y L+ 1rQ /t`^ ]� �t G� •�G _Z CHECK If BILLING ADDRESS <br /> BUSINESS NAME \ T 1 I ' 1 G PHONE# EXT. <br /> Cnr- 2— <br /> HOME <br /> HOME or MAILING ADDRESS FAX# <br /> fit%, S+ / 3 ( ) <br /> CITY /a cl ( *.TATE ZIP q <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 or <br /> 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 JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGERJO OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirie <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Sameb"Maryt d to me or <br /> my representative. 9 #-%1KhICEIVED <br /> '�C <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: OCT 0 2 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ,��1/�flEMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 `vv EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 1 n() 7 <br /> Fee Amount: t� Amount Paid 1 �` Payment Date Z L <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />