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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR 6a _ c\ <br />a CHECK if BILLING ADDRESS <br />_ <br />FACILITY NAME ?Or\ bs fre s b <br />SITE ADDRESS <br />aL2)4.411 Street Number Direction W4-1.41#1- e Stre5fa-rne socod-N.,___ City <br />9 cdr)C <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />..,;•110 Street Number Coe 42_ ra e)St fla(me C $t 1) <br />Cry <br />'--q il C(*-P-rt <br />STA a ZIP q ca _ .. ,.. c p <br />EXT. PHONE #1 , , <br />COM -SCL(1 -.a,_610,. <br />APN # I I 7 .(poL-q- <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR --, REQUESTOR6 <br />CU1Gk- lav -c_r- CHECK if BILLING ADDRESS <br />BUSINESS NAME eon ES presso b 1-c OLP-e_ PN 3z9-C72(SIT . <br />HOME or MAILING ADDS FAX <br />ca:2-1 10 t <br /># <br />CITY L.,( rv STATE (.7a ZIP i-15;13 co <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 appl ation and that the work to be rformed will be done in accordance with all SAN JOAQUIN <br />Cowry Ordinance Codes, Standards FL and FED AL laws <br />APPLICANTS SIGNATUR <br />PROPERTY BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <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 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 Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: PAY MN I <br />COMMENTS: RECEIVED <br />Neu) tr,:itA LQ i MAR 20 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: <br />END 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08