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SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RACE REQUEST# <br /> S <br /> Do�2� <br /> OWNER/OPERATOR <br /> CHECK 11 BILLING ADDRESS <br /> />1 G o 5,E ifeHA ON- v L <br /> FACILITY NAME <br /> SITE ADDRESS aSSS131EVr—A 1,AMF— 5-FDC�O/� <br /> Street Number Direction /Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /7sy G'/�l E20(��E ,QDAD <br /> Street/Number Street Name <br /> CITY STATE ZIP <br /> G eA qS-eo_s <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE/ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> E CHECK If BILLING ADDRESS <br /> BUSINESS NAME t�1 PHONE# Err' <br /> L ao4-02-- <br /> HOME <br /> 0Z. -HOME or MAILING ADDRESS FAX# <br /> . D . ROX E 7 24 ( ) <br /> CITY ��LOL STATE q zip ?�/ <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 ENVIRONMENTAI..HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my businesAide fied on this form. <br /> I also certify that 1 have prepared this applic hat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandardsSTATRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I III-Lo <br /> I2O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> TfAPPLIC.9NT 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 to 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. P <br /> TYPE OF SERVICE REQUESTED:50 IL- SU 7—AO L <br /> COMMENTS: OCr <br /> (AQIJ <br /> e,At ' 1? 2020 <br /> IN <br /> T t RDNME OUAI)1' <br /> H DEP MFN <br /> ACCEPTED BY: � � EMPLOYEE#: DATE: Ow;C <br /> ASSIGNED TO: EMPLOYEE#: DATE: �J >a 0';C <br /> Date Service Completed (if already completed): SERVICE CODE:�O� P E: ax G)p-? <br /> Fee Amount: 46CIF Amount Paid �P01 D Payment Date <br /> Payment Type Invoice# Check# 3 6 Receiv d By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />