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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTn DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> k L r �. <br /> OWNER/ OPERATOR <br /> q� 6V A l 4.6 CHECK if BILLING ADDRESS C� <br /> FACILITY NAME Hof,-.en gor-'On <br /> SITE ADDRESS _•r� �Jq1'/{A ���. �e{vree g523 7 <br /> Street Number Directlon , Street?Jame C T4 Code , <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 3662 Street Number (O E lam( Street Name <br /> CITY STATE ZIP <br /> �' 82 7 <br /> PHONE#1 v' Ex-r. APN# LAND DUUSE APPLICATION# <br /> 0m) 7ozog9 -��s�c�7 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR ? <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> ae W A I <br /> BUSINESS NAME PHONE tk 71, <br /> 097) Ex r' <br /> HOME Or MAILING ADDRESS t <br /> FAx# ) <br /> 3552 dolts Crete k- L l ( ) <br /> CITY C7 i,,it y+�y Yhp�✓f /w STATE /LQ ZIP 9 G CSO^7 I <br /> c](� a v/a� i 1 QLJ �!� V O <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 HEALTil 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: Yzo <br /> G DATE: <br /> t <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGI4NT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> i <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 i <br /> provided to me or my representative, a <br /> T� i <br /> TYPE OF SERVICE REQUESTED: J!orl Su��abi�l anc� /Ultr„� {e I-Dric.4I,T �fUt� /�PY�IPw j <br /> COMMENTS: F. MENT <br /> • F ` CEIVED <br /> �IJV 0 3 2020 1 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: !�� EMPLOYEE#: ENVIRO ?hEALT �A S Q7 oa J <br /> ASSIGNED TO: <' < EMPLOYEE#: DATE: 11 131,7020 <br /> Date Service Completed (if already completed): SERVICE CODE: �a 3 P I E: 676007 <br /> Fee Amount: (,OF Amount Paid b Payment Date <br /> Payment Type V1.�;aL Invoice# 945k# J '�> L 8 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />