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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ow3og 0 <br /> OWNER/OPERATOR <br /> QS c D E T 6 c9 N2 N � c Z CHECK if BILLING ADDRESS 11 <br /> FACILITY NAME nN A <br /> SITE A'DDIRE,SSfS C A \(Z-go(L� S'r 0C.r�()^) gr2� 6 <br /> 2 I �l v Street Number DlreJction Street Name Cil Zi Cede <br /> J <br /> HOME <br /> or MAILING ADDRESS (If Different from Site Address) <br /> 7 (D OLAtL �i n/n Street Number r� Street Name <br /> CITY Sr o ( 6irc�t� ` � rv2P/kN sT TEZIP <br /> -^ ) D <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (ZO9 ) S 7 0 6 L Lt <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex T, <br /> MA(LIS CoS M �z�T�A � o . s -3- 0 67 e <br /> HOME or MAILING ADDRESS FAX# <br /> bs © ZA Cl ( ) <br /> CITY %T O C frit ti i C ` p-o(LN v p STATE C s2l S 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, STATE and FEDERAL laws. /I2 <br /> APPLICANT'S SIGNATURE: �� ����c. o-s ti- 4 z <br /> ,r DATE: t 2 r > �l 20 2 0 <br /> PROPERTY/BUSINESS OWNER tr OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If 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 <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: <br /> COMMENTS: <br /> san,�AC 3 <br /> H&Zf pEp�LX 1Y <br /> ACCEPTED BY: r EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEEM "C��$' DATE: •L <br /> Date Service Completed (if already completed): SERVICECODE:O /f <br /> 6J P/E: 3 <br /> Fee Amount: IOU Amount Paid 6a Payment Date <br /> Payment Type Invoice# Check# JIB 5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />