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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST . <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -2 ZZ O =5 10, <br /> OWNER I OPERATOR rtt-7'' Q <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME //V_ II t9 V N719 -a PA Silo I <br /> SITE ADDRESS 15 I 6 -.J}—��RLAN RU�'I - I�i7-I -op 9S -33o <br /> f Street Number Direction tree) a e CI ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (AD ' ) 3�t� —G s a mom. <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 1N D i w--AJ O ' am 3�0— a s <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 /> I also certify that I have prepared this application and that the work to be perfonned will be done in accordance with all SAN JOAQUIN . <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: A, DATE: 10— 3�—2�090 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPL/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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> RECEIVED— <br /> COMMENTS: <br /> OCT 2 3 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ( EMPLOYEE#: DATE: I J Z� <br /> ASSIGNED TO: I EMPLOYEE#: DATE: lot <br /> Date Service Completed (if already Completed): SERVICE CODE: 0ll/E: 0 <br /> Fee Amount: j�'Z .L7ti Amount Paid i1Z9 2 ._-. Payment Date vV 2— <br /> Payment Type 1/�Cyn Invoice# C Ck# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 1,1/17/2003 <br /> P�v�38c��L S <br />