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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> I Y3 <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> OWNER/OPERATOR <br /> A4/]a � � a ✓ L L � CHECK If BILLING ADDRESS <br /> FACILITY NAME �� � '+ l <br /> SITE ADDRESS G O z JC <br /> J Street Number Dlre¢tion � l 0 / trNet Name (-� CI� �D Zf Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)H <br /> 02 AAFI L b ' / Street Number Street Name <br /> C&Y STATE ZIP <br /> oc o , � -�/ 12d <br /> PHONE#1 P"T• APN# LAND USE APPLICATION# <br /> qt)j q 7 �i <br /> PHONEY EM• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 'L + j PHONE# EXT. <br /> HOME or MAILING ADDRESS <br /> d wt rdcrjP t �9 ( # ) <br /> CITY �O C / a STATE ,n ZIP G <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. 9 s� <br /> APPLICANT'S SIGNATURE: o �4�����('�� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BiLLlyGPARTY 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 availGtl}� t1 aj jIIC*same time it is <br /> provided to me or my representative. �+//�{����CN r <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: NUV 16 2020 <br /> SAN JOAQUIN COUNTY <br /> ENIARCINMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: G, EMPLOYEE#: % DATE: <br /> ASSIGNED TO: EMPLOYEE#: rH /� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:J pit: <br /> Fee Amount: J UV Amount Paid J�.2 Payment Date It <br /> Payment Type 6 Invoice# Check#Cp? 116,qa o O q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />