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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _ SERVICE REQUEST# <br /> PA <br /> 23652 �CJ�/J <br /> OWNER]OPERATOR <br /> GIFr L-\( <br /> CIE CHECK if BILLING ADDRESS <br /> A 'ZiN ufE 0 0w 6 W-5 C C <br /> SITE ADDRESS {� I A ,Ii/' r-- <br /> � t / 9—TOC <br /> Street Number Dlreollon r1—Street�me •/ 1. Clr v I JZIP Cod. <br /> .}HOME or MAILING ADDRE,,S�tS,� (If D�itQferent from Site Address) ` 'f/-'1� <br /> 1 U— I N Dg <br /> j Street Number L L) StfreAl`Nfm <br /> CIN C STATE ZIP 9j, FT (•(, <br /> -3 ` , <br /> PHONE#t EXT, APN# LAND USE APPLICATION# % -f <br /> X64o <br /> 1 ) s <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> I I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR LV f T� <br /> K- CHECK If BILLING ADDRESS <br /> 1 <br /> BUSINESS NAMEPHONE ExT. <br /> f 5 <br /> HorM8 G ADDRES <br /> I M 6 VAJe> FAX# <br /> 2— I ) <br /> CITY G STATE ZIP <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 bus' lified on this form. <br /> I also certify that I have prepared t ' applihat the work to be performed will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Stand rd , S ERAL laws. © / <br /> APPLICANT'S SIGNATURE: DATE: O l b <br /> OPERTY/BUSINESS OWNER❑ T ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not t RTY 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at �same time It is <br /> provided to me or my representative. o. y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: U6 , <br /> �avJO 2020 <br /> q <br /> H�<lyOO���-1�lY <br /> ACCEPTED BY: ' /J t A na EMPLOYEE#: 220 DATE: <br /> ASSIGNED TO: vvxc r EMPLOYEE#: •rlY DATE: 17 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 : 16U3 <br /> Fee Amount: U Amount Pai G�7 b Payment Date F/ z1, 23 <br /> Payment Type �S Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />