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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A ano A5N 3 S2 cog q-4-13 <br /> OW—I OpERATOR <br /> _ ,\���� f� �� 1� �1 CHECK If BILLING ADDRESSMimam � <br /> ,rFACILITY-NAME ^ e:J el)`l Q r ` A JC�F J <br /> SITE ADDRESS `VI ..7 OV S Fr� <br /> Vo"' -q <br /> �v�✓l' � -I�j�Z <br /> Sheet Number a tla treat a e Ci ZipCode <br /> HOME or MAILING D ESS (If Different from Site Address) <br /> ��S o <br /> 1 (S/�� �Q Street Number -Street Name <br /> CI � �� CME - , �-i'ZIP r <br /> PHONE#1'-f ExT. APN# LAND USE APPLICATION# (D <br /> `A ) G20-2 3 42 Iy°� 031702 <br /> PHONE#2 EXT. BOS DISTRICTOQI LOGON CODE <br /> ( ) V <br /> CONTRACTOR / SERVICE REQUESTOR <br /> AREQUESTOR"r,l' �^ /� ,/� r- /CHECK If BILLING/1ADDRESS <br /> C T$DSINESS-NAM ET^ aJC` �A� (MOE CA ri �. HONE#E l0 O �2�Y2 EXT. <br /> If HOME or MAILING ADD/RE/'SS FA%#V�LGJ <br /> 1ITY-SQA V DSc �T ' IPICt,S 2 <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 /> 1 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 SIGNATURE: ATE: - <br /> PROPERTY/BUSINESS OWNERM OPERATOR 1ANAGER ❑ OTHER AUTHORIZEDAGENT❑ <br /> If APPLICANT is not the BILLING PARTY 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 t0 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. PA^YeFur <br /> TYPE OF SERVICE <br /> �REQUESTED: �M0 <br /> C yt <br /> COMMENTS: c / 4 FEB 12 2020 <br /> ACCEPTED BY: (\\A/lA/1 EMPLOYEE#: DATE: /2. kk 20 <br /> ASSIGNED TO: J W EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 11 PIE: I W O 2 <br /> Fee Amount: It nz— Amount Paid y,L9 Payment Date -- aN ,go'Z.A <br /> Payment Type Invoice# rCheck# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ' <br />