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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SSERVICE REQUEST# <br /> If U 1?A L F ID T L Mql�-OqL <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING ADDRESS <br /> /,') EA NA ZZI-61 oe M T-0 <br /> FACILITY NAME 5C <br /> SITEADDRESS 7046- F- ;FDA/,( ,AIVENuE MAN75CA (5337 <br /> Street Number Direction Street Name Cit 6 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 71425- FAST sFDAAl A ✓EtdKF <br /> Street Number Street Name <br /> CITYA,V w'�CA $TATe- ZIP <br /> A ` <br /> /�/ 3 Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# ?-5-3!Z l <br /> �2pg ) (�o7-ao 6 C;U(l- oo-�� <br /> PHONE#2 EXT. BOS DISTRICT ` LOCATION COD19 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L G CHECK If BILLING ADDRESS <br /> BUSINESS NAME (I� PHONE# EXT. <br /> CM bw ) 40,�-- 5-a <br /> HOME or MAILING ADDRESS FAX# <br /> 3724- <br /> CITY <br /> CITY 1— STATE ZIP S 3 <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..HF..AL_I'ti DEPARTMENT hourly charges associated with this project <br /> or activity will be billet{to me or my business as identified on this form. <br /> 1 also certify that I have prepared this a ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandarcts r I't=and laws. <br /> APPLICANT'S SIGNATURE: DATE 2Z � /gyp <br /> PROPERTY/Bt.SINESS OWNER OPERATOR/MANAGER ❑ OTHER AOT'HORILED AGENT L� <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 ENVIRONMEN'TAt.I-lF,AT.TH 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:JOjL SN t < Br,L E S PA <br /> COMMENTS: <br /> CE jvp p <br /> MQY 1 8 2020 <br /> ,10A U/ C pU <br /> HF�T RONIN Nr NN <br /> ACCEPTED BY:��� Z �� EMPLOYEE#: DATE: S' / Z T <br /> ASSIGNED TO: /\j A EMPLOYEE#: DATE: <br /> Z <br /> Z- Z� o <br /> Date Service Completed (if already completed): SERVICE CODE: -,�3 PIE: d(-0-1 <br /> Fee Amount: Amount Paid -Va <br /> Payment Date P5 <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />