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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS rJ ,13C - C�t�O �_ ��.�� 1 <br /> abort Nvmbvr Diredlvn Slrevl eme CIzip Cale <br /> HOME Or MAILING ADDRESS (If Different from Site Address) \2fdpStmp�or\�,gyt� CGv <br /> Sheet Number eat Na.. <br /> CITYW`YA014"I STATE ZIP <br /> PRONE#1 I=• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE 92 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR__\ <br /> 1 o CHECK If BILLING ADORE55 I <br /> BUSINESS NAME - — PRONE# • <br /> (19N).442--A-u-42- <br /> HOME or MAILING ADDRESS FAX If <br /> 1 5 N.V s kv I ( ) <br /> CITY l— STATE C-q zip2 <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 /> 1 also certify that I have prepared this applicati nd�h t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , ATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 42-02.0 <br /> PROPERT•/BUSINESS OWNER[] CIERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT • �) <br /> 1fAPPLICdNT is not the BrLLING 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 t <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/Dr environmental{'ee assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the`slrtllY#ari(is� { <br /> provided to me or my representative. eRSA ��IGIY <br /> TYPE OF SERVICE REQUESTED: W411- i, <br /> COMMENTS: <br /> SANjo 2020 i <br /> EQRQ(/INCOU <br /> MpA� EPgR ;NT <br /> ACCEPTED BY: EMPLOYEE#: � 3 DATE: "S <br /> ASSIGNED TO: EMPLOYEE#: b8 CF DATE: LJ i <br /> Date$ervice Comple ed ((,already completed): SERVICE CODE: rLl sj/ PIE: <br /> Fee Amount: Amounl Paid VS-6.03 Payment Date <br /> Payment Type 6 Invoice# Check# /��7 Received By: <br /> EHD 48-02-025 _ SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> �R�S'�to Otp� <br />