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411! SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />r h <br />owNE, i uPERATOR <br />"v <br /> <br />FACILITY ID # <br />FAD07.00 I 5 <br />SERVICE REQUEST # <br />--Qq0b7c9 3 141 <br />‘s _jacc\N <br />._.., <br />' , L9C-7. _ <br />CHECK if BILLING ADDRESS <br />i FAcitrry NAME ._ \ <br />SITE ADDRESS '--I <br />2.. LI 13 Street Number <br />1D <br />,., <br />Direction <br />C\( EVO C •- .5:,;(1 <br />Street Name .\' 0 C K1 City c Zbil',4de <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />12 ) Lk E LA Y_) \( U\ \ - Street Number (...A Street Name 131 -- - "? () <br />CITY CITY STATE ZIP <br />PHONE #1 EXT. <br />(201 (481-- I-11-9, <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />tA 6- Ne-\ —CA_ C,.. - , <br />( ..... II) V-3 01 /4.,,cf 0 v, .4.---(.. 443\N <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />\--1, k e.".• t <br />k <br />\ ,C1 \C.V. \ ---1:3 Ve_AA,, \ --ci\ <br />PHONE # <br />( 2_4[. I 1 <br />EXT. <br />HOME or MA ING ADDR,E S <br />0 1 ? \c-- • D.—\c <br />FAX # <br />( ) <br />CITY Er, AT <br />‘ A-ST <br />ZIP CA 9 ,, i: <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 Of <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: <br /> <br />PROPERTY / BUSINESS OWNER El OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <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 iesults, 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 same time it is provided to me Of <br />my representative. <br />_ <br />TYPE OF SERVICE REQUESTED: Ftzd vaLiq.2, -r,-n 0--y, Re6":6`4. <br />COMMENTS: DEC 0 2 2016 <br />SAN JoilQu <br />ENvilio IN couN HEALTH 0 mENTAL <br />EPARNEN <br />DATE: t'2/20 Ato <br />DATE: 1"21211( <br />ACCEPTED BY: EMPLOYEE #: <br />ASSIGNED TO: te.4,Ajec(,,r1 Ile ir) ha,t7e5- EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: ,,5C4:;621. PIE: <br />Fee Amount: 413 Cl- 07 <br />Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)