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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> POW� t ((\ 00 203ILC*�n3�b <br /> OWNERI OPERATOR � � ��Ii� � � <br /> ��'I/Und/1/I rOf CHECK IfaILLINO ADDRESS <br /> FACILRY NAME 1`� l� '��r rt �...) <br /> SITE ADDRESS f� sn��I�l, <br /> 9treetN Ger Dree o ,V' t� HSS 1 tN a CI J Codao <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street N m e <br /> CITY STATE zip <br /> PHONE#1 ExT AEN# LAND USE APPLICATION# <br /> (204 <br /> PHONE#2 aT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _\ � ^� CHECK If BILLING ADDRESS <br /> BUSINESSNAME �nl.r.�� \ PH QN � E- <br /> HOME OF MAILINe ADDRESS ^ FAx t # ) <br /> L / V <br /> CITY�i"I/A V• ell PZIP 6)5 3v <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,Standards,STATE and FEDEI laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BOsimss OWNER❑ OPERATOi NAGER OTHER AUTHORIZED AGENT 11 <br /> IfAPPLxANT 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: <br /> COMMENrs: <br /> lvr <br /> RECEI veb <br /> Ep <br /> AUG <br /> 72020 <br /> SAE JOApU/N <br /> ACCEPTED BY: EMPLOYEE#: �1�41 DE'1ART7AL <br /> ASSIGNEDTO: ���� ,e EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: O(�` PIE: <br /> Fee Amount: \ S•Z Amount Pal ��i Payment Date V 7 k7 <br /> Payment Type Invoice# Check# /b 330'7/ I Rece ed By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />