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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> ---i Ga vo'92"1'N <br /> OWNER/OPERATOR <br /> -l` �JY,�- �'^�' �� CHECK If BILLING ADDRESS <br /> FAcamNaME� �y� LS <br /> SITE ADDRESS S Z ' <br /> Y"�l.+�Straet Number Direction �v`�� Name v <br /> HOME or MAILING ADDRESS Different from Site Address) Q <br /> �1 Street Number iJ � Street Name <br /> CI ^^ <7— aq_ -moi` STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHO.p <br /> N.E#2 EXT. BOS DISTRICT LOCATION CODE <br /> (Lt/ \) oz?-- C-1:DC> <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> To OA m , "rU n 6htj W0(W- CHECK if BILLING ADORES <br /> BUSINESS NAME j J s �viY/ le Ppgf{F ,`-1 EXT. <br /> HOME Or MAI ING AD RESS r / FAx## U <br /> 2 r 19 *A ( I <br /> CITY -S STATE /'A zip A <br /> C5 2Z <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 a pltCa ' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE anj FEDERAL laws. <br /> APPLICANT'S SIG DATE: L V <br /> PROPERTY/BUSINESS OWNSJW OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 1-- `` <br /> IfAPPL/c,&T is not the BILLING PAR Tr 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�1��}.Athr S time It tS <br /> provided to me or my representative. fir+ TT ——wit <br /> TYPE OF SERVICE REQUESTED: V h� a <br /> COMMENTS: OCT 2 3 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE-) ,5 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: 'Z 00 Amount Paid 4/ S 2 Payment Date Lv 2 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />