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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> A <br /> CA 1 () a r �b95 CHECK If BILLING ADDRESS❑ <br /> 01 �.-1 (`,1� <br /> FACILITY NAME � ^ � � <br /> SITE ADDRESS /L q 00E ~- ��11� , „ WV6 Sty, _ P�SZ-0-J <br /> Street Number Direction Street Name (, T Y-�"Cit Zip Code <br /> HOME or MAILING ADDRESS (If Di erent from Site Address) <br /> r C <br /> –� K+lU IP Street Number Street Name <br /> CITY �C✓ STATE ZIP ^s'1O <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• [g&i DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � <br /> C1(6 C—as In r /Y/U I►/�l C,-,Cs <br /> � CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6-V <br /> CITYes C 1-- i� jam- Sr T ZIP (� 2 <br /> Cr ` <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. <br /> APPLICANT'S SIGNATURE: J�Kh100 KL) OQf) f�) `03 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 /> 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. PMMENT <br /> TYPE OF SERVICE REQUESTED: ( L 1(� 1 �� . J1, RECEIVED <br /> COMMENTS: DEC 2 8 2020 <br /> CG'�GLVI�C o.� OV�MQ 2�In�, <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /1"�� EMPLOYEE#: DATE: 12 Z h`717 v <br /> ASSIGNED TO: \J 1 ``( ^f�C `) EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I nP/E: <br /> Fee Amount: Amount Paid - Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />