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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH RPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # • _ <br />ice- LY •eO- yy\ <br />ifpf -21 0w to <br />SR 067b"5i- <br />OWNER/OPERATOR UA vL kr_ <br />D\ h-) <br />,^ V_\� <br />4/IL CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS �' <br />[ULD Street Number Directlan <br />Street Name 1 v CIZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />C c - � F i o w er <br />CStreet <br />Number <br />Street Name <br />CITYzip <br />S o C_ K b� <br />co 0 P01 . 2 12 <br />PHONE#1 EXT. <br />APN# <br />Payment Date - _ a O .) 7 <br />LAND USE APPLICATION# <br />(z�_7 <br />) �'��-l9 <br />�Chk�g <br />1, <br />PHON412IR <br />BOS DISTRICT <br />LOCATION CODE <br />_ vV <br />CONTRACTOR / SERVICE REQUESTOR 6 <br />REQUESTOR <br />CHECK If BILLING ADDRES <br />BUSINESS NAMEvl` C - C^ <br />'• c CY2�� <br />PHONE# <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY G `C STATE GA 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 />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, STATE and FEDERAL laws. Q <br />APPLICANT'S SIGNATURE: PRAM qA � DATE: 2 —Z 0 — I <br />PROPERTY I BUSINESS OWNER q 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, 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 same time it is provided to me or <br />my representative. <br />VMWIMQUESTED: <br />RECEIVtu <br />FEB Lb 2017 C 1q (t-196'6 oq <br />AN JOAQUIN COUNTY <br />ENVIRONMENTALENT <br />bDn _Pr, Li G <br />ACCEPTED BY:ltdt-7 <br />EMPLOYEE#: <br />DATE: P, _) Ci - <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: � ' dt� /7 <br />Date Service Completed (Ifialready completed): <br />SERVICE CODE: / <br />P I E: AlLj <br />Fee Amount: <br />Amount Paid C7 <br />Payment Date - _ a O .) 7 <br />Payment Type Cc, cJ <br />Invoice # <br />�Chk�g <br />Received By: <br />U � <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />