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SAN JOAQW.4 COUNTY ENVIRONMENTAL HEALTH UtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RI�UEST# <br /> voce A 5 0 V-' I <br /> OWNER/OPE TOR r l <br /> , C,r-lG. ova�'\JP C/ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> `1 SIn51A� 5 V1,00 Ase <br /> $ITE ADDRESS <br /> Street Number I Direction I Street Name city ZiD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ` <br /> II 1Je✓l <br /> - 1 Y Street Number ` Street Name <br /> CITY STATE ZIP <br /> S\-o(-L-A-(''-\ (�-V:\ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR� CHECK if BILLING ADDRESS <br /> 1 tnr� G. VP <br /> BUSINESS NAME PHONE# EXT. <br /> Mhr I S o' S't S ',) )Lc-'l (0,?- 1"(5& <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> S 1-o Ck)li ry (✓a et S. 6 <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 /> 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: �� ( —�� DATE: 3 <br /> PROPERTY I BUSINESS OWNER�M OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme tion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time Ior <br /> my representative. rr,, <br /> TYPE OF S rml : I W bi Jm2d V U V( )r) y 5g <br /> COMMENTS Ec l � � ( N COV (`( <br /> P v i V�ro C)9 mai+ t 60I� <br /> MAR 2 2 2019 SO4 EPPR Nj <br /> SAN JOAQUIN COUNTY N Nom' <br /> FWRONMF DEPATMENT <br /> ACCEPTED EI /�r6f EMPLOYEE#: DATE: 3111 <br /> It <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE. <br /> Fee Amount: Amount Paid lc Payment Date <br /> Payment TypeInvoice# Check# Received By: a <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />