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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> FA aoi2qYY 0 0 %�*914 U (0 S <br /> OWNER / OPERATOR <br /> � V„ CHECK If BILLING ADDRESS <br /> ❑ <br /> r-cc) ccs 4 1, ssSI�S J c�,t� o <br /> FACILITY NAME C a 4 C <br /> c S <br /> SITE ADDRESS LO'CvA L � Q ��� ( � q� <br /> Street Number Direction ll S eat Name Cit Zi Code <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 /> ( ) 1W 220 1 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 00 t <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I , \ CHECK if BILLING ADDRESS <br /> BUSINESS NAME ti PHONE # ExT. <br /> HOME or MAILING ADDRESSII �� (AX # ) <br /> ai LVI� I <br /> CITY STATE CA ZIP e? vqc%�3 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 IaWS . <br /> I . <br /> APPLICANT' S SIGNATURE : �� 0 =1 U Ub .. DATrEG 1 (� � �✓n ,� <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT LCI Cb Lk-�/ k - <br /> /f APPLICANT 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me Or <br /> my representative . T <br /> TYPE OF SER q rN 'r u S 1 MI n o r pl q .vl Cf�LQ�f� C-h�'u� <br /> COMMENTS : RECEIVED <br /> OEC 1 8 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : S`17` IC1w , EMPLOYEE # : DATE : <br /> ASSIGNEDTO : 61 ) C(ohna Or 0( 0 EMPLOYEE # : DATE : /2/21 <br /> Date Service Completed (if already completed) : SERVICE CODE: G/ 8 29 8 P / E 23 <br /> Fee Amount : ( 62 40 O Amount Paid ���� Ud Payment Date / 2A4rl2wl <br /> Payment Type 0 Li Invoice # Check # 7z4 rReceived By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />