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.X, <br />Quo 3ca�25�v <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />COMMENTS: cc <br />?��> ice. <br />f{IDA <br />-FA2 z i <br />Sr2 Cb�2CP <br />OWNER / OPERATOR %� <br />A <br />if BILLING ADDRESS <br />�Y „/.,TL )CHECK <br />FACILITY NAME <br />hSgC'��E <br />SITE <br />ii�� <br />6treet Number <br />Dlraetlon <br />«N <br />C <br />ZiCode <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />EMPLOYEE#: <br />6213 <br />Street Number <br />ASSIGNED TO: Vidal Pedraza <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PH NE 1 SOS/q ,N EM' <br />APN # LAND USE APPLICATION # <br />P / E: 3602 <br />Fee Amount: 304 <br />Amount Pai <br />PHONE #2 /MAC. Ab4a+4S Ezr. <br />SOS DISTRICT <br />LOCATION CODE <br />((6-7f 7 <br />Payment Type <br />11 <br />CONTRACTOR / SERVICE REQUESTOR <br />BUSINESS NAME <br />CHECK if BILLING ADDRESS O <br />HOME or MAILING S� 4t le Cf- i (A%/�) e y eaj (I <br />CITY C d rr L✓fl STATE /1. zip 6Fc O,> /: <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 prcjec <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 tfrbe performed will be done in accordance with all SAN JOAQUf <br />COUNTY Ordinance Codes, Standards, STATE and FEp9RAL laws. ) I <br />APPLICANT'S SIGNATURE: DATE: <br />�}y) ♦�� <br />PROPERTY/ BUSINESSOWNER❑ OPERATOR /MANAGER ❑ THER AUTHORIZED AGENT El t�be9p Zl�-y+L,.ry2 <br />If APPLICANT is not the BILLING PAR 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 th <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessmer <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thep ptime it <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: PCJJZ(yti f - A -L7, <br />c `�N <br />COMMENTS: cc <br />?��> ice. <br />f{IDA <br />T <br />SAN✓ ��2� <br />N�f <br />hSgC'��E <br />q C <br />MFNT <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: <br />6213 <br />DATE: 9-30-20 <br />ASSIGNED TO: Vidal Pedraza <br />EMPLOYEEM <br />fi213 <br />DATE: <br />9-30-20 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 523 <br />P / E: 3602 <br />Fee Amount: 304 <br />Amount Pai <br />. OD <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # `l <br />ff,5387s <br />Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Ror <br /><O <br />