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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR0082676 <br /> OWNER/OPERATOR <br /> CHECK ifBILLING ADDRESS <br /> ® <br /> FACILITY NAME <br /> SITE ADDRESS L? <br /> Street Number Direction Street Name <br /> cilyZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE#1 ✓7'9,0 14 s'�.J0 �1 ,ExT• APN# LAND USE APPL@CATION# <br /> PHONE#2 *114t, A 11+b' S E-- BOS DISTRICT LOCATION CODE <br /> ( A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �} e � � PHTE fE Exr. <br /> HOME or MAILING ADORES r, /�v FAX# <br /> CITY %5 46 V STATE ZIP —® <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 proje( <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 1be performed will be done in accordance with all SAN JOAQuI <br /> COUNTY Ordinance Codes,Standards,STATE and FEPERAL laws. <br /> r <br /> APPLICANT'S SIGNATURE: /)41 ' DATE: i��.0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THER AUTHORIZED AGENT❑ too I- <br /> IfAPPLICANT 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 tb <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmet <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ����[ 7f A ' �C � /k5 �IPe t�'o <br /> COMMENTS: 0 <br /> '(;,;> 40P(A--5-TSir— <br /> AcCEPTEr)BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 9-30-20 <br /> ASSIGNED TO: Vidal Pedraza EMPLOYEE#: 6213 DATE: 9-30-20 <br /> Date Service Completed (if already Completed): SERVICE CODE: 523 P/E: 3602 <br /> Fee Amount: 304 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Roc <br />