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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00J `Crime\c e`512� 00- Z l0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> So U` � ` <br /> FACILITY NAME i CA 49 11C` `` A_ <br /> SITE A DR'E`SS 1 V ..,, <br /> 7-CAO o Street Number Direction �� `reef .a -3 CI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Ad ress) <br /> 'Z5--4T Street Number C '��Ireel Nsme <br /> CITY STATE ZIPn <br /> PHONE#t Ea. APN# LAND USE APPLICATION# 7 <br /> ( ) 51'� T2—'W'� <br /> PHONE#Z Ea. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> SDI!I o� v CHECK If BILLING ADDRE5Sa <br /> BUSINESS NAMEPH E# Em <br /> S r2�aa 2 — — �o�J� « ZZ <br /> HOME OrMILING AD ESS FAx# <br /> 2 f t S ( ) <br /> CITY 9f 0 L „ STATE ZIP G� <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 FED <br /> PPLICANT'S SIGNATURE: DATE; <br /> �—/zllzdz� <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER OTHER AUTHORIZED DATE: <br /> PROPERTY <br /> IfAPPL/CANT 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 availableft�d�l irpe time it is <br /> provided to me or my representative. I IIYYIn IVr <br /> TYPE OF SERVICE REQUESTED: 1 <br /> COMMENTS: 2020 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTTY <br /> AL <br /> HEALTH DEPARTMENT' <br /> ACCEPTED BY: t�( �,� EMPLOYEE#: DATE: S •21 l�J <br /> ASSIGNED TO: 1., EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: b <br /> Fee Amount: Amount Paid-1��`d Payment Date 2,C)C) <br /> a�[Invoice <br /> Payment Type # Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED I W 7/2003 <br />