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SAN JOAQ.._.J COUNTY ENVIRONMENTAL HEALODEPARTMENT <br /> SERVICE REQUEST <br /> t <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P� U v <br /> OWNER/OPERATOR / /TI <br /> Gt rt l.Yv 2 0 r rP Z CHECK If BILLING ADDRESS <br /> FACILITY NAME / <br /> ©5 C�rIS CSS �1 ct(bq <br /> SITE ADDRESSl � A <br /> / t' T� <br /> Street Number Direction Ca`r tQl0ee am5 � C�cion t Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) R� <br /> If Street Number 105 <br /> r�C� Street �' <br /> CITY 1 OGK STATE zip �o <br /> oh <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (!20 7) S3-0",15 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> q05CJ a t�(a e r-v2 o rre2 <br /> BUSINESS NAME PHONE# EXT. <br /> a Losc S ; .za �d9 c---q5- 4, <br /> HOME or MAILING ADDRESS / p FAX# <br /> � � ►rLt'yI [ d t (� r� ( 1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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. <br /> APPLICANT'S SIGNATURE: 1_-V CyC/Z DATE: O 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Tule <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 tithe it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L e �.�� T <br /> COMMENTS: <br /> MAR 1 1 2020 <br /> � AQUIN COON <br /> NftpK��°Mr MNT <br /> ACCEPTED BY: �. \ EMPLOYEE#: DATE: 7 \\ ZU <br /> ASSIGNED TO: S• ���� EMPLOYEE#: DATE: —,2-_> \\ `�O <br /> Date Service Completed (if already completed): SERVICE CODE: /� \ PIE: Y <br /> Fee Amount: ���t�'Z Amount Paid Payment Date , <br /> Payment Type Invoice# Gheck# Received By: /J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />