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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 14 l R/, Ga i f 4- r2, CXD L4 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> IV • <br /> FACILITY NAME <br /> /! G• p <br /> SITE ADDRESS 7317 'P C— <br /> LTiQ <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) oZ "3 5/4 A/I'VIA R G 0 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 5A t,' 3 e-A 4 4oGG <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> klG- IL ar3-Oao-3 / /�A 003 <br /> —11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CON'rIZACTOR/ SERVICE REQUESTOR <br /> REQUESTOR L/ <br /> DO e S CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> /l/r l co N S v '" O OZZ - S <br /> HOME Or MAILING ADDRESS FAX# <br /> toZI <br /> x 3 ( ) <br /> CITY u A L0 STATE ZIP 5-3 91 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 appli jition and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S" T'and F RAL laws. <br /> APPLICANT'S SIGNATURE: J" <br /> DATE:_ 9A��9 <br /> PROPFRTV/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IR/ ' <br /> If APPLICANT is not the B11,1,ING PARTY_proof of authorization to sign is required Title <br /> AUTIIORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. PAYMElyr <br /> TYPE OF SERVICE REQUESTED: PL,� Cy�L'�� RECEIVE[) <br /> COMMENTS: SEP 11 2019 <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): 1 ��6 1 SERVICE CODE: PIE: 7 it <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 / SR FORM(Golden Rod) <br /> REVISED 11/17/2003 / <br />