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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# cSERVICEREEQ/UEEST# <br /> V 'S v0 O <br /> N ER_IOPERATOR! <br /> C y / n ^CJC—e CHECK If BILLING ADDRESS <br /> W Y 1 <br /> 4F.AGILITY'NAME� � 1 ✓ /���7,L <br /> q$ITE/ADDRESS �2yy(�` S <br /> Str¢et Nu 2.r Direction Street Name City Zip Code <br /> HDME'Or MAIL'ING7ADDRESS (If Different from Site Address) S ! l I�J� D # S <br /> Street/h Number Z Street�Name <br /> C`ry 1^ , STATE / / ZIP q S7 ' ' <br /> P.NONE#1 JT lUl�-' Ems• APN# LAND USE APPPLLIICATION# <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE _1V <br /> l ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR c ,n ` m&-yz <br /> .�"L/r YL-C7r CHECK if BILLING ADDRESS <br /> BUSINESS NAME C-PiY/i1��, PHONE# Ex*. <br /> HOME or MAILING ADDRESS001 C ' rndo IJ„� FAX# <br /> CIN Cki CGN+"L�0 STATE ZIP /71 G-7 - <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 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 Coder,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 11 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 <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 available and at the same tiirte It is <br /> provided to me or my representative. c®� <br /> TYPE OF SERVICE REQUESTED: Q N 1 CL s/( G (�, co V- <br /> COMMENTS: <br /> C tnutVAtisC v �wv(p eSLt w "0' 17 2020 <br /> ISAIJ JOAQUIN <br /> &MRONM COUNTY <br /> \' HATH TAL <br /> OEPAR7'MeNT <br /> ACCEPTED BY: 7 ��'� EMPLOYEE#: DATE: ,I— 12-2-0 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: P I E: QO? <br /> Fee Amount: 4 1C32 w Amount Paid /0 l�,b� Payment Date 711Z, <br /> � .7 <br /> Payment Type ° Invoice# Check# C (o l Recei4cl By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 6111 5 <br />