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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 400:2,5C26? G4, of q <br /> OWNER/OPERATOR <br /> n/�, I CHECK If BILLING ADDRESS <br /> FACILITY NAME 5Y 'l/,�I \0 5 (�/p ` 'l <br /> SITE ADDRESS 6 . 1 <br /> - tom, ( r C�� n ���� <br /> /IJ/�/i1 Street Number Direction l V Street Name CI 111 Zi Cade <br /> HOME or MAILING ADDRESS((If'Different from Site Address) , <br /> ^lStreet Number tr am <br /> CITY STATE ZIP /� <br /> PHONE#; / !-> 3En' APN# LAND USE APPLICATION# C� <br /> qo� <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 0110, CHECK If BILLING ADDRESS <br /> BUSINESS NAME S \ ` �'^ n ^� PHONE#) ' <br /> n EV-0 <br /> OME Or MAILING ADDRESS \ tel/ FAX# <br /> Mr ( ) <br /> CITY 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 Coder,Standards STATE and FEDERAL <br /> (� ` laws. <br /> APPLICANT'S SIGNATURE: � eA--t,� <br /> DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MR <br /> OTHER AUTHORIZED AGENT❑ <br /> lfAPPLICANrisnottheBiLiNGPAR proofofauthorizadontosign isrequired 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. e <br /> TYPE OF SERVICE REQUESTED: C 0 YJ <br /> COMMENTS: F,f <br /> NOV 16 ?021 <br /> JOAQIJ <br /> ACSIN COU <br /> SMF <br /> V' <br /> ACCEPTED BY: S EMPLOYEE#: �e) 7 DATE: <br /> ASSIGNED TO: r EMPLOYEE#: )79 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �03 <br /> Fee Amount: a --- I Amount Paid 5Qr Payment Date 1 l alp <br /> Payment Type Invoice# c l 3 Lf Received By: <br /> EHD 48-02-025SR FORM(Golden Rod) <br /> REVISED 11/17/2003 /) ClwqS <br />