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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICEREQUEST# <br /> Skooi�� <br /> OWNER/OPERATOR ase ��• I TJ .. rr�ra /� (} CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME y�Lr •�t�V� q((�*f0. Cr/1�C'� <br /> SITE ADDRESS r I �C �a <br /> W C O f• vJ <br /> Street Number Direction r [reel rva e � � � � <br /> —54 we <br /> HOME or MAILING ADDRESS (If Different from Site Address) -L-L(S ii , I <br /> Street Number U'` ' Street Name <br /> CITY STATE„ „ ZIP <br /> PHHqONE#1 �r mss, ExT APN# LAND USE APPLICATION# <br /> PHONE#20 <br /> /N �^�� EKT. BOS DISTRICT LOCATION CODE <br /> 'velli IJ.Y� IYY�L. Cy,� CONTRACTOR / SERVICE REQUESTOR <br /> REDUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME f'c�60 y r•C'l �A U[� „IO O PNONE Q �j EXT. <br /> J 1 J l (� Zo (s' E �f 21Q <br /> HOME or MAILING ADDRESS 2Z15 Q (q f S-� FAX# <br /> ( ) <br /> C17Y C STATE ZIP <br /> ✓ TA <br /> BILLINGACKNOWLEDGEMENT: �G <br /> 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. A <br /> APPLICANT'S SIGNATURE: 2Z DATE: I`' 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT❑ <br /> If APDL/CANT 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 /> infortmation 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. <br /> TYPE OF SERVICE REQUESTED: Vt4(U <br /> COMMENTS: rxI= JVE'D <br /> r 2 6 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPART <br /> Ehir <br /> ACCEPTED BY: �I �nA.t..rt EMPLOYEEM DATE: <br /> ASSIGNED TO: J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0W PIE: <br /> Fee Amount: It5z— Amount Paid tFa Payment Date 20 <br /> Payment Type CI Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />