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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 0 SERVICE REQUEST# <br /> S r,� 1IC -71q <br /> OWNERI OPERATOfj.� M <br /> lyr ITS\ CHECK if BILLING ADDRESS <br /> FACILITY NAME `n 1 <br /> SITE ADDRESS 1 �r\�) <br /> UStreet Number Dreclraw�l Sireel(Name ZipCode <br /> HOME or MAILING AD RESS (If Different from Site Address) \f <br /> l -` C ` 6Street Number Street Name <br /> CIN -tC N C n1 J\ STATE C 60KZip ��2 <br /> PHONE#f �•U EXxIpAPN# LAND USE APPLICATION# J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ; CHECK If BILLING ADDRESS <br /> BUSINESS NAME fnAZL(f �a� �Ji I.. PHONE# EXT. <br /> HOME Or MAILING A_Q E$S � ch / '((/�l/','',��((�//�� FAx# ) <br /> CITY Il U l`ca Cd 4/�S--t)�(0 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 /> 1 also certify that I have prepared this application an (that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT an F ERAL laws. 1 //�I— I �, <br /> APPLICANT'S SIGNATURE: DATE: `U � l �C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MeAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APDL/CANT is not the B/LLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. ft <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> sq^coq 6 2020 <br /> N BNS1, /V� <br /> B9CZHRD�T q�Nry <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 Z(P ` -0 <br /> ASSIGNED TO: tk aNl EMPLOYEE#: DATE: V ul T6 <br /> Date Service Completed (if already completed): SERVICE CODE: OV f PIE: I (Q03 <br /> Fee Amoun : S 2— Amount Paid / Payment Date O 2,6 ) <br /> Payment Type Invoice# Check# Received By: yvi <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />