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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FG 02 2 lk S I <br /> OWNER/OPE7L/ <br /> TOR -- v- CHECK If BILLING ADDRESS❑ <br /> t S e SAA V60124 JfADC,1,1A <br /> FACILITY NAME —60 <br /> SITE ADDRESS --y� <br /> ►J S, CAW )(Zlilo Si STUC/-C �faSU� <br /> Street Number Directlon Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from-Site <br /> Site Address) ��.fl G& WAA <br /> V/ 7/ I D&a Street Number �� f Street Name <br /> CITY ('✓� TO STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# ✓ S <br /> ( 50) 331 -7016- <br /> PHONE#2 ExT• BOSDISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �J <br /> 1vl3 f 54A V� ENS CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT' <br /> vs 6L A I S!o 331 -- qoU <br /> Home or MAILING ADDRESS FAx# <br /> Ill 7 R-0&a <br /> CITY OD(5-51,� STATE ZIP S3 1 <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,Standard r, STA andE=� <br /> APPLICANT'S SIGNATURE: DATE; /p� p�B'l"20 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If/APPLICANT is not the BILGING 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tinge it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: :::02(d Cons a bWOL4 <br /> COMMENTS: l <br /> DEC 2 8 2020 <br /> 4" °RQu11V counr <br /> ry <br /> ACCEPTED BY: rril EMPLOYEE#: � DATE: <br /> ASSIGNED TO: I r� EMPLOYEE#: ?22510) <br /> 1 n DATE:— 12— <br /> Date <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: U 3 <br /> Fee Amount: 152'u Amo unt Paid ' Ira Payment Date <br /> Payment TypeMIA <br /> Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />