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SAN JOAQUIN COUNTY .ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 5ERVICE REQUEST# <br /> OWNER/O ERATOR <br /> C CHECK if BILLING ADDRESS 19/ <br /> FACILITY NAME <br /> V SvJNE2 <br /> SITE ADDRESS f/�7o0 .1-0— /`/� VF-2 RD . /� pp�( g3U44G <br /> Street Number Direction Street Name------ city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> 04 ) 6-77-3/oi6 - �- O - -oo <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> E <br /> UESTORN Q (�5 L CHECK if FILLING ADDRESS <br /> INESS NAME PHONE# EX*• <br /> e r�t(�. V(N E R o � <br /> HOME or MAILING ADDRESS FAX# <br /> le 0o 2D. ( ) <br /> CITY STATE ZIP <br /> g53GG <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 ENVIRON'`•E.NTAt..HEALTtt 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 an lat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar n JE , L laws. <br /> APPLICANT'S SIGNATURE: D:1TE: 24 <br /> ✓fir ZO�-O <br /> PROPERTY/BCSINFSs OWNER[3 OPERATOR/MANAG FR ® OTHE.RAUTHORIZEDAGENT❑ <br /> I(APPLIC AN'T is not the BILLWG 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: S E LO <br /> COMMENTS: <br /> RECEIVED <br /> JUL 2 7 2020 <br /> SAN JOAQUIN <br /> ENVIRON COUNTY <br /> ACCEPTED BY: EMPLOYEE M DATE: �TT <br /> ASSIGNED TO: dl,G EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIC: <br /> Fee Amount: %o k Amount Paid C)8- Payment Date 2`� 2d <br /> Payment Type01jq� Invoice# Check# lo Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />