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d FF.DE:Rm., laws. <br />OPERATOR / MANAGER 0 OTHER .NUTHORIZED AGENT 0 <br />COUNTY Ordinance Codes, Standards, STAT <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER Er/ <br />DATE: A71- 1///f <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Corn ni IZ'C( A L - riZu CK-.1 n( <br />FACILITY ID # SERVICE REQUEST # <br />Gi2... 00%1'4613 <br />OWNER I OPERATOR <br />CHECK if fii a • RANS(/- 5 t N4 i-1 i'v15 • OAKAl2-74 rY leygk. BILLING ADDRESS Er <br />FACILITY NAME., <br />e &IF -TRUCK TE.R114(14AL- <br />SITE ADDRESS 2...c <br />Street Number <br />Fiz g i q c 14 CA rktP 12-44b <br />Direction Street Name <br />FKEAle.k/ 4.4sir <br />City <br />16334, <br />zip code <br />HOME or MAILING ADDRESS (If Different from Site Address) I 746D <br />Street Number <br />fn 0 gpR y toA Rtz-t4/4y <br />Street Name <br />CITY STATE ZIP <br />1-4174 RD r CP• q5-31C? <br />PHpNE #1 <br />3 c5'- 5-700 <br />EXT. APN # <br />1'7'3- 070 - 14- <br />LAND USE APPLICATION # <br />PA - - 1 g 0 o2_ SI <br />PHONE #2 <br />I ) <br />Err. BOS DISTRICT ,i LOCATION CODE <br />4a <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />PR. C'14i10//4/POR MAN4Ar CHECK if EiR,UNG ADDREU a <br />BUSINESS NAME <br />rizeidcH (4 en P 714.14Gie....Tega 1 avAA- <br />PHQNE # <br />(-IV) .35-5-- 5700 <br />EXT, <br />HOME or MAILING ADDRESS <br />I 7 9 6 0 0711gPAly PA oZiLtd,/ <br />FAX # <br />CITY <br />L An"( MP STATEN1 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 <br />or activity will be billed to me or my business as identified on this form. <br />I also cert4 that I have prepared this application and that the work to be performed will he done in accordance with all SAN JOAQUIN <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 <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 availabloyMetee time it is <br />provided to me or my representative. <br />— FttNil--1 ` - <br />TYPE OF SERVICE REQUESTED: Pt_ A ni CH E--c (1-- <br />COMMENTS: DEC 0 6 2019 <br />"I nt4 COtIt'frf AN JOA‘A-- - -TAL <br />S RONMEN ENV) opormENT <br />tiEALTH °Er <br />ACCEPTED BY:404......_) -_,L, EMPLOYEE #: DATE: I <br />ASSIGNED TO: 774 EMPLOYEE #: DATE: ( <br /> <br />I Date Service Completed (if already completed): SERVICE CODE: c2/ <br />Fee Amoun114), Amount Paid ,._- <br />Fs4 ,r <br />Payment ate t <br />:td <br />Payment Type 4( Vi /sk. Invoice # Check # 0 i F / Received By: <br />s2- - 1 END 48-02-025 REVISED 11/17/2003 44. 46-2 - Us. SR FORM (Golden Rod) Vf2ot lb 2411276