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SAN JOAQUIN ,OUNTY ENVIRONMENTAL HEALTH DEFARTMEN1 , <br /> SERVICE REQUEST TD <br /> T( Qy�peofBusinessorProperty FACILITY IDS#7 SERRVVIICEE7REQUEST# <br /> OWNER If OPERATOR n 4- �-Q 1') ; ( ' CHECK If BILLING ADDRESS <br /> FACILITY NAME 1v ` 1`.fX_� <br /> � a� Sla� ccoSS , 0-1 <br /> SITE ADDRESS reATtnef (<t ucf �f'. $ToC(C7o� 9 Szlg <br /> Street Number Direction I Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2131) qsz. - 55�-7 i ► bl l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) ©I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> TLS t 1 STc�O r r0` jO r CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 ` l d PHONE# EXT. <br /> oolTMe ql (�P'59-7665 <br /> HOME or MAILING ADDRESS <br /> CITY 6 p'1P �,v C f CA_ STATE ZIP <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 r TE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> � ;77 <br /> PROPERTY(BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTjLF [coot —r,'Me M{F NCLG CI' <br /> IfAPPLicANT is not the BILLING PARTY,proof of authorization to sign is required Ttrt¢ <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the,�3rJTp�ima it is provided to me or <br /> my representative. c AYF nV�� <br /> hu <br /> TYPE OF SERVICE REQUESTED: R e — Q� RS7l' r 5 R RECEI <br /> COMMENTS: JAN 17 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTALNT <br /> HATH DEi <br /> ACCEPTED BY: , EMPLOYEE#: DATE: _ x <br /> ASSIGNEDTO: vej� EMPLOYEE#: DATE: _ / <br /> Date Service Completed (if already completed): SERVICECODE: G,2� PIE: <br /> Fee Amount: 0 Amount Paid O Payment Date . ' 7 <br /> Payment Type CInvoice# Check# G 5 ► 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117/08 <br />