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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �^SERVICE REEQUEST# <br /> 00S 701 acs <br /> OWNER I OPERATOR <br /> /n u l C�7��G, /n ��J f� l �j`� CHECK If BILLING ADDRESS <br /> FACILITY NAME i RX `T--k Or 1 C�- "l 0�)(A Ci�,\ <br /> SITE ADDRESS 1A 3t1 <br /> Street Number I Direction l� Street Name W / l ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1��"I CA VZ l brZ tD 1L vJAI�., 41r- <br /> Streat Numbar Street Name <br /> CITY C STATEN\ ZIP <br /> PHONE#1 J Ems' APN# LAND USEAPPLICATION# <br /> 9,91 ) <br /> PHONE#2 Ev. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Em <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CIN 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 17-01 -to <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BitmG tt proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO ATION: 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 /> TIDE OF SERVICE REQUESTED: FVO ?(tan OAC C� NT <br /> COMMENTS: D <br /> DEC 042020 <br /> VlOA771oU/N CouN7'y <br /> D4 �MNJ <br /> ACCEPTED BY: ,�./1�-� EMPLOYEE#: DATE: 12-1 H I'0ZD <br /> ASSIGNED TO: 11 U�IV J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 5Z2,, 11E) <br /> Fee Amount: Amount Pal Payment Date <br /> Payment Type Invoice# Check# Receive By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />