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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> "FPt 0000 l 5�{ o�ZsS I <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> t Gf t <br /> FACILITY NAME Gl OI C,1-e C( MU K.� <br /> SITE ADDRESS .� 1c5 1l/S l-. � ' T") ��� �yn�rA ' Cq m)O 01S2� <br /> Street Number Direotlon 1/ Siree Nama Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)) <br /> ZStreet Number Street Name <br /> CITYa A Y Y-a,A-c CSTATE ZIP 9 V/16 <br /> !V <br /> h <br /> PHONE#1 U�Err. APN# LAND USE APPLICATION# Y <br /> ( `//S) 2)q 3 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t <br /> N^ � / +1.. r„^ k I 11 I CHECK If BILLING ADDRESS <br /> BUSINESS NAME' G V� ak`r'l YyN 91 n � PHON;# 5 Q _� 3 14 <br /> HOME or MAILING ADDRESS FAx##1 <br /> CITYn ��rQ I cb STATE ZIP 9w/v <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 Coder,Standards,/SETAATTEE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: T y�G'/ 7/1�� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <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. PMMr <br /> C^ �e EN'�q <br /> TYPE OF SERVICE REQUESTED: �� D I/1 I RECEIVED <br /> COMMENTS: <br /> ��� �kl Ot/�P�esltit,aP NOV 0 6 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ` / HEALTH DEPARTMENT <br /> ACCEPTED BY: y PAUA&n 1l)l EMPLOYEE#: DATE: 1I-W-210 <br /> U, <br /> ASSIGNED TO: K- n 11 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: (002 <br /> Fee Amount: c)y, Amount Paid K 15 Z _ Payment Date Lt <br /> Payment Type IT Invoice# Check# O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1 0 ^I��� <br /> r IW <br />