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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Celf&/"w,fh fco6K -etigwe'*- <br /> OWNER/OPERATOR ` p <br /> 2 nw- C L�Z°T CREcK if BILLINo ADDRESS El <br /> FACUTY NAME fa,rlfcr <br /> SITE aoDREss61-o f S���wMc�rto Sf GocG; 4S�GlG <br /> Street Number I Direction Street Nacre CRY Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 613/ 7 ��Lp v <br /> Street Number •J� <br /> CITY LOCS_C//( /STATE 6'4 <br /> ZIP 4qI��� <br /> PHONE#1 ExT• APN# LAND USE APPPPLICATION# / <br /> ( m ) 3;L7 (3'q( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> l 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR fa-rff1 f 6 f CREcK if BILLING ADDRESS <br /> BUSINESS NAME PHDNE# Gtr• <br /> fet,124 Yct.W x.04 ) 3 <br /> HOME or MAILING ADDRESS 61) U FAX# <br /> (i ( ► ! ,/ <br /> Cm L0C'/ STATE / ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: 2 DATE: 10 <br /> PROPERTY/Busmss OWNMO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> 1fAPPL1CANT is not the B1LL NG Paltry.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 erwironmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENwRoNMENTAL 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: rz<� cry- _ L,,� PAYMENT <br /> COMMENTS: <br /> OCT 2 1 2020 <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: C��f L EMPLOYEE#: DATE: to .2 <br /> ASSIGNED TO: EMPLOYEE M DATE: \� Q -u <br /> Date Service Completed (if already completed): SERVICE CODE: P/E:t 0 2 <br /> Fee Amount: S Amount Paid S Z Payment Date J p JV 2jp <br /> Payment Typetj•� Invoice# �# lr S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br />_ REVISED II/17/2003 ���PV 5 <br />