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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT1 I J�f�/�I <br /> SERVICE REQUEST IIJJVV <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> 5 q <br /> OWNER/OPERATOR • <br /> G LAIR <br /> IR CHECK If BILLING ADORESSO <br /> FACILITY NAME 1 J ' ` <br /> SITE ADDRESS p�-"f" Lgtl <br /> 5treetVNumber Direction I -I Street Name 'I(/ L`ll••( t/I I `�� Z/I Cotle lX <br /> HOME or MAILING ADDRfiSS ( Different fr,/o�m Sitss) <br /> r U 1 e AddreStreet Number Street Name <br /> CIT' I /vL}`-,. rY q G STATE ZIP <br /> `HONE 1 y 5)-��� ExT• APN# LAND USE APPLICATION# <br /> ro,mPHONE )80 /y BOS DISTRICT LOCATION CODE <br /> CCXXJJ b CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ; n1S bffi <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME _IS K 1,) pr <br /> 0 # -5a - ' 1 Cj EXT' <br /> HOME Or MAILING ADDRESSt �(� 1/ ,1` All^1��� s (A%# ) y I <br /> IIV• l/`J 1 l <br /> CITY c-04r n CA- 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 FEDERAL laws. p <br /> PPLICANT'S SIGNATURE: �(jrs� ( �}�t2�T.91 DATE: —IO <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAlepvc NT is not the BJLLINGPARTY.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. <br /> y I,, � <br /> TYPE OF SERVICE REQUESTED: I C OMS 1 It�I�t I OI,/I <br /> COMMENTS: VCQ <br /> 4tpR 1 C <br /> B 2021 <br /> Mob' I e OE NrAj J? <br /> ACCEPTED BY: MAN EMPLOYEE#: �r DATE: <br /> ASSIGNED TO: I /p`/'i I T EMPLOYEE#: V DATE: (J t <br /> Date Service Completed (if already completed): SERVICE CGDE: OLP I <br /> Fee Amount: -U O 1 Amount PaidI�a Payment Date 11612- <br /> Payment Type Invoice# Check# Received Bair <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />