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SAN JOAQUIN l-OUNTY ENVIRONMENTAL HEALTH ilk-a-ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Gt(Z Ont i 1 k <br />OWNER! OPEWOR <br />Fl? V bo-\-0 1\)\etAtleZ CHECK if BILLING ADDRESS <br />r ,..-.\ ,.., <br />—) DU Ka-S Cia5 <br />FACILITY NAME 00 ma <br />SITE ADDRESS <br />tisk 2-7 Street Number Direction \i"NA_Ke.)r Street Name <br />IdkcirOVe_CCX <br />City <br />953-3G <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cry STATE ZIP <br />PHONE #1 EXT. <br />(2°C ) -) S2- I\ CD., <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex'r. <br />( Zdi ) -Ng- cDPYS <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r__, „ <br />if k0 1\•k0Ylde 2_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />—D (ik— Ma C-0 S 1 .C.t.spCAS <br />PHONE # Exr. <br />(zcc) -7s2-tC 0G <br />HOME or MAILING ADDRESS <br />1 14 .L1 c7 ro-t el& c.' <br />Fax # <br />( ) <br />CITY 1\.k_Ct fa ,\--.e_cck STATE e_ ci ZIP ci5-33 („ <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 TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: moor- DATE: Q9 —O 4 2-C) t9 <br /> <br />PROPERTY / BUSINESS OWNEREI 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 <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 />y— . . <br />TYPE OF SERVICE REQUESTED: c'1206\ UNANAX\11A/A-V <br />r-s-a a m . <br />RFCFIVFD <br />COMMENTS: <br />SEP 0 4 2019 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: \. OW Vt0 EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />i <br />. hiblA9 OW EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: <br />1 <br />I E . \* <br />Fee Amount: /t SC / _ 4',19e <br />Amount Paid <br />, ) - L_ Payment Date <br />/ <br />,--.) Payment Type Invoice # Check # Receive By: '9( <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003