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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# � SERVIC"EQUEST# <br /> Y OWNER/OPERATOR CHECK If BILLING <br /> ADDRESSn // f/L V--(QmOii <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Qpau. ( Stret Number I Direction /-/'qrW/';VStmetNaui9 w / <br /> � cityZI Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) td ecce A✓e <br /> V C7 Street Number treat Nam5 v�� <br /> Cn CITYSTAT ZIP <br /> !" PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> 6-09 ) SLID �t-1 ?L( <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> �o REQUESTOR ❑ <br /> VL 0A -ruez-Y11/4Pz CHECK if BILLING ADDRESS <br /> p <br /> BUSINEScoS NAME PHONE# Exr. <br /> l 9v�Ya �� SL Cv �L/ SZ <br /> HOME r MAILINGADDRESS d l� ' c (AX# ) <br /> CITY O ,t0 C �} `/ V STATE PCZ F ZIP GJ 5 r.,C' 5- <br /> BILLING <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. Q <br /> (O APPLICANT'S SIGNATURE: J1 / f DATe: q !?q — G O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY prOaf Ofauthorization 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 envirTessent <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available�qa EmDne it is <br /> provided to me or my representative. �1��Ir <br /> �� <br /> TYPE OF SERVICE REQUESTED: 61) SEP 2 2 2020 <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: viubr A <br /> EMPLOYEE#: DATE: /y2 <br /> ASSIGNED T0: , EMPLOYEE M U r DATE: <br /> Date Service Completed (if already completed): SERVICECoDE: I P I )3 <br /> Fee Amount: 2'/Y) Amount Paid f(( 1,3 2_ Payment Date Z� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />