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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly =-a � IL�JY ID#� ^ _SERVICEREQUEST# <br /> OWNER/OPERATOR U�`)'LJ,/vel <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME //11 ` "11 l _ VIII/A� <br /> ! l.d V1AdVV\ � & <br /> SITEADDRESSZa U E. aot ,t 1�y _ S� ockFC) h �I52o5 <br /> Street Number Dlreotion G kA <br /> S'� I,I, m 1o V% 0a <br /> CI ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 22®�{ d2 G�k <br /> Street Num berSVeet Name <br /> CITY Zip <br /> S �0r_vVQh SLT� 11 '5212 <br /> PH0NE#1 EXT' APN# LAND USE APPLICATION# <br /> ( U'4 5114 - ?-,I Li (� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 6 O CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT' <br /> HOME or MAILINGRF,SS FAX# <br /> G Y ( ) <br /> CIN ATE 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 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,Stand s, STATE and FEDERAL laws. ` <br /> APPLICANT'S SIGNATURE: DATE:/) �=�n Z� <br /> PROPERTY/BUSINESS OWNERK- , OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f 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 t0 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: <br /> COMMENTS: <br /> �GrS�'►i E/VED <br /> G� of our P JUL 1 <br /> SAN J 2020 <br /> E OAQUIN <br /> ACCEPTED BY: W1AM IS . EMPLOYEE#: IB(J� T <br /> ASSIGNED TO: EMPLOYEE#: 32 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ✓O I P 1 E: 1003 <br /> Fee Amount `v* Amount Paida — Payment Date Y 2U <br /> 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />