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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />EM <br />7 7% p <br />C <br />0 <br />5rz ��-7 yto 3 <br />STATE <br />ZIP <br />"<- <br />OWNER/OPERATOR <br />M�tiil <br />l✓\ <br />�t4t�L'V <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />c I <br />SITE ADDRESS 1 <br />/�1` <br />/'_ ,Le ,., i' _ _L <br />t..r(J�.'1 Y—�-1 <br />C'.tb4-� <br />c� <br />Street Number <br />Direction <br />StreeI NN.m. <br />MIN <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />ItO 7 1' �`+� tiL1 <br />n �" <br />Street Number <br />Street Name <br />CITY <br />STATE /` ZIP �O <br />PHONE #1 <br />EZT <br />APN # <br />LAND USE APPLICATION # <br />(Z01 -?77- z9-70 <br />oo3 <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />-• V � L C <br />CHECK if BILLING ADDRESS <br />K////n1111 <br />BUSINESS NAME , \PHONE <br /># <br />(7-M <br />EM <br />7 7% p <br />HOME or MAILING ADDRESS <br />7 P. ti til <br />FAX# <br />( ) <br />CITY <br />STATE <br />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, S TE anddFFEEDDEE�`L laws. <br />APPLICANT'S SIGI TRE(�: %/// V/ l/ A DATE: <br />PROPERTY/ BUSINESS OWNER L^Y OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT Is not the BILLING PARTY, proof of authorization t0 sign Is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 san�Y�riLi&.arc yled t0 me or <br />my representative. Ai MEIN 1 <br />RECtIVE <br />TYPE OF SERVICE REQUESTED: FEX eb.LC-yt_0Q -- D <br />COMMENTS: JAN 19 <br />2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: �j 5 1 I _ ". EMPLOYEE #: DATE: I r ' <br />ASSIGNED TO: c../ J'r EMPLOYEE #: DATE: 1 0 <br />Date Service Completed (if already completed): SERVICE CODE: c, � PIE: "I <br />Fee Amount: ct Amount Paid - Payment Date <br />Payment Type, Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />