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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '5 c- 00 D- <br /> OWNER/OPE R ` CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS C/C > r <br /> Street Number Direction Street Name Cit Z Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> " r r� Vvd�- t - -" tum- " <br /> 1-1 ` Str Nher � Street Name <br /> CIN O r G STATE ZIP <br /> PHONE#f Ezr• APN# LAND USE APPLICATION If <br /> RC) ) //<2-t,-- 60 6, <br /> 3 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS E] <br /> N-D \AAC <br /> BUSINESS NAMEr� P E# E'D' <br /> s m0 U�r e P CJ C o 0 Cy -�16Y6 U <br /> HOME Or AILOGADDRiSS FAX# <br /> 0 A6foY Ire dey K �� r ( ) <br /> CITY Q C� Q ^ STATE ZIP <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���t� ���� e.� DATE: <r7 C� <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT it 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. <br /> TYPE OF SERVICE REQUESTED: [to <br /> PAYMENT <br /> COMMENTS: q� 1 ' d �C � 1 w „ 1REICEIVED� <br /> tl`T"�'rc-J (tel "�l fW�Pi1f( NOV 0 3 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: \1✓ <br /> ASSIGNED TO: EMPLOYEE#: DATE: V\✓ <br /> Date Service Completed (if already completed): SERVICE CODE: �'U 3 /E: <br /> Fee Amount: S2 Amount Paid S 2 Payment Date <br /> Payment Type VL n Invoice# l l 7 3 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />