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e <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Ar6tr � j,-vlt,Its <br />BUSINESS NAME[� <br />u r ke$ PVv I IGS �% /lo <br />FACILITY ID # <br />SERVICE REQUEST # <br />'39,0673); <br />OWNER / OPERATOR <br />CITY r' r U I'1 STATE L f zip <br />CHECK M BILLING ADDRESS <br />FAciuTy NAME ,r <br />I/ �TWJOG J'I pC(% 1✓Vt P,' <br />IJ <br />$ITE ADDRESS <br />Stmet Number <br />W <br />mre I n <br />("� I I ' fie P! d <br />11 f Stroet Nemacrty <br />) <br />%�iL >' <br />q53�c <br />ZIP Code <br />NOME Or MAILING ADDRESS (If Different from Site Address) <br />Shot Numbor <br />SER WE CODE:3 <br />Street He <br />CITY <br />Amount Pald <br />STATE <br />zip <br />PHONE SI <br />( ) <br />APN# <br />2 <br />LAND USE APPLICATION# <br />PHONEii2 EMT' <br />( ) <br />BOS DISTRICT <br />L30 <br />LOCATION CODE <br />O <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR C Jlcl 11 �UI1 <br />{{-- CHECK If BILLING AGGRESS <br />BUSINESS NAME[� <br />u r ke$ PVv I IGS �% /lo <br />PHONEM Ezv <br />zcq 94 331 <br />HOME or MAILING ADDRESS -( ��� <br />AX# ) <br />CITY r' r U I'1 STATE L f zip <br />BILLING AWGV1?L DGF.MENT: 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 <br />or activity will be billed to me or my business ac 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 FFD laws. <br />APPLICANT'S SIGNATURE: DATE: I(-; O_L <br />PROPERTY I BUSINESS OWNER❑ OPERATOR/ MANAGER ElOTHER AUTnoR=v AGENT V(-" r I> Wr't n <br />1fAPPuc4NT 1s not theB¢ci.vGPARTr 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 da(a 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, pA I - <br />TYPE OF SERVICE REQUESTED: <br />RFC FHl <br />COMMENTS: <br />J, T <br />44 <br />6 10 2017 <br />H M105 <br />)HOF <br />ALv,'V� <br />4FA'T <br />ACCEPTED BY: <br />EMPLOYEE #: ( DATE: O of e 1 <br />ASSIGNED TO: <br />EMPLOYEE#: 3 DATE: 10W1 1-7 <br />Date Service Com ted (if already completed): <br />SER WE CODE:3 <br />PIE: <br />Fee Amount:b <br />Amount Pald <br />0D <br />Payment Date (O , <br />Payment Type �' 5,p --Invoice <br /># <br />C134k# �73� <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />