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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST )09 0//v 7535 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3�(g <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> SAZ �P4-TPeQ-- �t.t',Ss,.�C.S 1rl_� <br /> FACILITY NAME <br /> GI p-C-L-✓ y{ <br /> SITE ADDRESS C-i.u� 3�vD STC-t4--zo.-1 9S 2p+j <br /> S ? S� Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ez. API# LAND USE APPLICATION# <br /> (7-09) 932 - 130 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME J f I PHONE# E' , <br /> St} ( (Cft4zAt� Jc S LLC Z^9 X32 - 13 O7 <br /> HOME or MAILING ADDRESS ^} FAX# <br /> �-5-75 �' u rJ�tlL� �1J t7 �L✓�' ( ) <br /> CITY STATE <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 o to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,SlAy• and FE ERAL l S. <br /> APPLICANT'S SIGNATURE: DATE:A 7'd 24 <br /> PROPERTY/BUSINESS OWNER YJ OPERATO 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 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 /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: RECEIVE <br /> OIA otrsh � FES 2 2 2021 <br /> J SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: v V DATE: y2 7j J <br /> ASSIGNED TO: 4/ EMPLOYEE#: DATE: 2 y y 1 a7 <br /> Date Service Completed (if already completed). SERVICE CODE: P/E: I ll�V <br /> Fee Amount: "P- IOU Amount Paid ' S Z -- Payment Date 2/2 2/Z <br /> Payment Type C t?f Invoice# Check# I O�O Received By: <br /> EHD 48-02-025 SR KRM(Golden Rod) <br /> REVISED 11/17/2003 <br />