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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::::] FA Oo Zq G�3 S>2 00g 305c) <br /> tOVVNER/OPERATOR <br /> L6Qmor-10 <br /> r1p �U � O Y,e Z CHECK If BILLING ADDRESS <br /> FACILITY NAME G-1 JE L I qq, 'n�l(/V <br /> SITE ADDRESS 015p' S WG -I t7�Gt�Lo � -i-/`Q nc.In DArvtp L15231 <br /> Street Number Direction Street Name City Zip Code <br /> `SME oror MAILING ADDRESST(If Different from Sitedres/�S) <br /> C-n (C3 e- DStre//DD�� <br /> et Number Street Name <br /> CITY , STATE ZIP <br /> CYk s–"�O 91 <br /> (PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST= r VZ CHECK if BILLING ADDRESS <br /> ` a �O rreZ <br /> BUSINESS NAME l 1.. —Fn {�' PHS Exr. <br /> ^ ONE <br /> TW M�a or RMAILIN `DRE S FAx# <br /> t---/D - �n c 6� I > <br /> C`rv"^! Q-,-, N -/ ^ STATE ZIP q5,2 <br /> a <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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNAT`TREJ. E aSl a &Z17— E:-1 t�^ 20^ 2020 <br /> PROPERTY/BUSINESS OWNER <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 0 <br /> If APPLICANT 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the smie time it is <br /> provided to me or my representative. ft <br /> TYPE OF SERVICE REQUESTED: �QCI cros'A Avtl-LOvC� <br /> �– <br /> COMMENTS: <br /> CV (lka[u Y 0 0 A)VUIZC-VLGp ^ytVJOgC?? <br /> v VC <br /> (YIarwr+ '� H �o�u�NFNT <br /> I�sicle c��1dn� Gtl� <br /> ACCEPTED BY: rin().n EMPLOYEE#: DATE: I Z 2Z •G-^� <br /> ASSIGNED TO: K,L t EMPLOYEE#: DATE: lJ <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0 I P I E: O <br /> Fee Amount: +I C�z Amount Pai � �� Payment Date f 2O <br /> c <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />