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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'i FA- OW-1 Z IS X12 009Dl'!�2(cl <br /> OWNER/OPERATOR � � s A Co <br /> �I e �,� p /L-1L CHECK If BILLING ADDRESS <br /> FACILITY NAME ( o I rn ��n 4- 3 h -L' ' n <br /> SITE ADDRESS v1 00� Vv t4-C1 00 r 2 `v/1 [/^ �7(S <br /> Street Number Direction Y t StrVeet Name Ci "l Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) II Ow yV` 01� ,nC/►� ��v( <br /> Street Number 1 ► S'treet Name <br /> CITY (Q STATE DA, ZIP J <br /> ' <br /> PHONE#11 ) �1/� EXT• APN# LAND USE APPLICATION# <br /> Of LJ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� 1 nn 1.^ot(/ V7!1I�! A- <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �1 „V�/^ &„^ LA 1,�`� P L4 <br /> HOME or MAILING ADDRESS' (�/Yu ✓ FAX# <br /> CITY ��/ y� _, STATE ZIP S—]t <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 /> 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. rr�� <br /> APPLICANT'S SIGNATURE: e'z, n'1-Q' DATE: <br /> PROPERTY/BUSINESS OWNER 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, 1, 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 t0 me Or <br /> my representative. MYMENT <br /> TYPE OF SERVICE REQUESTED: RMEIVED <br /> COMMENTS: <br /> FEB 1 1 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRO'' i, At <br /> HEALTH ; <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O P/E: <br /> Fee Amount: 1q7 Amount Paid Payment Date <br /> Payment Type `r .I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />