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SAN JOAQUII —OUNTY ENVIRONMENTAL HEALTH —PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COO a 1 ru C K <br />FACILITY ID # SERVICE REQUEST # <br />Gt, cog, o_ao S <br />OANER / OPERATOR <br />1Y-kie-0 r ad L0 2 CHECK if BILLING ADDRESS <br />FACILITY NAME <br />VI co$ <br />MCI Street Number Direction <br />SITE ADDRESS ADDRESS <br />AO C\A.1..C-KStreet Name V f . Ant (OCkitv <br />(4450/ <br />Zip Code <br />HOME or MAILING ADDRESS (If Differerrt from Site Address) <br />\k4 ;\(\0\ckck C V- 01 , Street Number Street Name <br />CITY <br />PcY\k CY\ <br />STATE (yA ZIP <br />PHONE #1 EXT. <br />25 )G 2a- i? 2RS <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />(-a, o L01000--- CHECK if BILLING ADDRESS <br />BUSINESS NAME To caz LC),1 A \-k--ekos PHONE # <br />(qz ) CoZ8 - B Zas <br />EXT <br />HOME or NULLING aXRRESS <br />II1 <br />, A..., <br />r. vc G sact - <br />FAX # <br />( ) <br />CITY A nk‘ocs„,STATE CA ZIP 9c450 9 <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 prepare. s application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, S •ndards STAT EDERAL laws. <br />APPLICANT'S SIGNATUkOt lk <br />PROPERTY / BUSINESS OWNER OPERATOR! MANAI ER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <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 isd at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: --\1:LAY\ 171G1V1 DU C L. RECEIVED <br />COMMENTS: OCT 1 4 2019 <br />sAN joio „.. <br />i.m A ,ENviRofg7pc„,c),u^n-y <br />--"NNENT <br />ACCEPTED BY: 1 6i. ok_ ev,,() EMPLOYEE #: DATE: k) <br />A,SSIGNED TO: .1 Q__, 0 k j EMPLOYEE #: DATE: <br />Date Service Completed (if alrea'dy completed): SERVICE CODE: L--D2 3 PIE: 100 <br />Fee Aniount: Al, Lo_.— Amount Paid .41 i .--- Payment Date <br />Paymtant Type V ..6-1)\A_ Invoice # Check # Received By: A, irly <br />EHD 4E3-02-025 <br />REVISE K)11/17/2003 <br />11-3'q --q 21( VVV7) <br />SR FORM (Golden Rod) <br />DATE: 10 fr.{ f t9