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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> u Z-- <br /> OWNER <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> IVA V6,,( 11A 1; M!5 �v c cq <br /> SITEADDRESS .7 3 p0 �/ D r5LTA T/ZA fy <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2 3 Z 5A N r41 A R,G O <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> ,q /3 2 u <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Gsb ) GAG - 96 -2/3 - oao- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CON'T'RACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> A <br /> /� -, CHECK If BILLING ADDRESS <br /> D D t4BUSINESS NAME ,V PHONE# EXT. <br /> GI ME o ► av vi - s-a- <br /> HOME or MAILING ADDRESS FAX# <br /> a- 0 , 36K R ( ) <br /> CITY .1u Z LU C l-,— STATE CA ZIP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S' Tr.and F'PIRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the B1i,LL\'c;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 <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 I NVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P- "MFNT <br /> TYPE OF SERVICE REQUESTED: /V(-ria-re I,p 0 AMI soh- el/i IFr{.t/ RECEIVED <br /> IED <br /> COMMENTS: <br /> SEP 11 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already comp' gid): SERVICE CODE: P I E: <br /> Fee Amount: 1 Amount Paid Payment Date <br /> Payment Type Invoice 11 Check# Received By: <br /> EHD 4E-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />