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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -ao� t c�{C�r ,3 a <br /> OWNER I OPERATOR <br /> V l Shcun T j D CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME - <br /> S EADDRESS ! CA ,5+va-4," 13S26).q <br /> —:1L�/ Street Number Direction Street Name City ZIR Code <br /> HOME or(NAILING ADDRESS (If Different from Site Address) <br /> 0tJ Street Number Street Name <br /> CITY±. I c 1 D STATE ZIP <br /> PHONE#1 K T`X_\ ExT. t APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQu ToR i 54w'-) �LwA t'Gt.IV1 UCo <br /> L�Ifw CHECK if BILLING ADDRESS❑ <br /> c�'� r, 5 ExT. <br /> BUSINESS NAME 1J1 PPHO '41 _T <br /> (� <br /> HOME or MAILING ADDRESS Pa 55 <br /> � (kFAX `O <br /> &0q ` <br /> I 2LV id <br /> CITY <- I V Gk f r. �U 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, STATE and FE RAL laws. <br /> 2PROPAPPLICANT'S SIGNATURE: DATE: 12 L2- <br /> PROPERTY <br /> ERTY/BUSINESS OWNED OPERATOR/MANA ER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not th e BILLING PAR TY,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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: 'Fncv (AfS <br /> COMMENTS: <br /> JAN 12 2021 <br /> SAN JOAQUIN COUNTY <br /> EWIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE. O J <br /> Fee Amount: 1G��, bo Amount Paid l 5�2 __ Payment Date <br /> Zzo 2- <br /> Payment Type Invoice# Check# Received By: AfY <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />