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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# � Rf jr vQ I� <br /> OWNER/OPERATOR w '2l <br /> uu CHECK if BILLING ADDRESS <br /> FACILITY NAME --TAco 7 y e'1 (� // <br /> SITE ADDRESS -7U <br /> 5l Y?A s� `/A �L <br /> Street Number Direction Street Name Cit Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) I l 2?) Q� (;zw 1 Street Number 1. Street Name <br /> CITY is ^ ` STATE //M ZIP <br /> PHONE#1 ,� x/�J Ems• APN# LAND USE APPLICATION# V T <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � I I 1 <br /> )•jam ` �`� CHECK IfBILLING ADDRESS <br /> � <br /> BUSINESS NAME 1_1\0,1`V/ P 2� E <br /> HOME or MAILING ADDRESS p Maj`,-5 nI7 \,a,a ,.,_ FAX 7 <br /> YY l t' <br /> CITY STATE ZIP 0 <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 0 -13- 2/— !/I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I,fAPPLiCANT 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 t0 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: 'l W/v4/C- <br /> COMMENTS: MENT <br /> RECEIVED <br /> JAN 13 2021 <br /> SAN JOAQUIN COUNTY <br /> FN\IIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: Mgli D�P�IR�MEPtIT I <br /> ASSIGNED TO: EMPLOYEEM DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: U J <br /> Fee Amount: Amount Paid r2- Payment Date �3 <br /> Payment Type InvoiCA.1.*fh1 I f q Z Y 6 Check# Received By: <br /> IV <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />