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SAN JOAQUIN ‘...JUNTY ENVIRONMENTAL HEALTH L ..,eARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />‘,/c• )7Ch (— Y. r, <br />FACILITY ID # <br />3-Q <br />SERVICE <br />101(. <br />EQUEST # <br />I'V 1 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />( (- Y)7 1 r's_C : . 1 '7 l <br />FACILITY NAME .__. <br />! • E L -1 V/ <br />SITE ADDRESS t--1 1 -1 <br />Street Number Direction MO( On Street Name S 0210 <br /> <br />Zia Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />7 e:/// V f-Y 77 ci - Street Number Street Name <br />CITY i STATE -4 ZIP <br />PHONE #1 Exr. <br />(32.) <br /> <br />T?-/ g 5? q3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />C Gui rY 1 G10 &I OrY.1-611 , (01-j1-111() CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />El an 4-Frk C.)'' <br />PHONE # EXT. <br />-5-) <br />HOME Or MAILING ADDRESS <br />:1: 1 I 114,-LAy 6 Y <br />FAX # <br />( ) <br />CITY - ,2-. <br />tc:)./C)c ory STATE / --- p_ ZIP Cl 3772 c, 6/ <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 Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 2 - 2.0 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: H-, Oh V <br />v • Reeigul;Wr— <br />IVeD <br />COMMENTS: <br />' l'ttj Z 6 2020 <br />44414 JOAcui <br />101\'' 41) cur CoKut-id, ....,ElvviA.v.,INcolAirv <br />i'vetifeAfr <br />ACCEPTED BY: Loin v ,,_c- . EMPLOYEE #: or g2x DATE: <br />ASSIGNED TO: 1<att,t440 1--- EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ((j ( PIE: I (4,6, ,,•r- <br />Fee Amount4 IS): k/I Amount Paid 6 (5-79 ,___ Payment Date <br />Payment Type Qiril Invoice # Check # Received By: (1E771. <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)