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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S'Q W Z°l Z <br /> OWNER/ OPERATOR <br /> -� CHECK if BILLING ADDRESS❑ <br /> J U /712b/t/ <br /> FACILITY DAME TAUA—� <br /> SITE ADDRESS I e 11 711 5.7 D n-tD ��Elde <br /> Street Number Direction Street Name Cit <br /> HOME or MAILING ADDRESS (If Different from Site Address) —73 y ) t.� 1A 46AJ C, AV-L-- , Ll <br /> L ( NU w/(r Street Number Street Name <br /> CI7]I ^ t r � ATATE ZIP_ <br /> PHONE#'I ExT- APN# �L-ANND USE APPLICATION#� <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RI=QUEST CHECK If BILLING ADDRESS❑ <br /> YL�- t> L1..�T IZvN <br /> BUSINES,s NAME PHONE# Ex <br /> —7110 <br /> © �� <br /> r. <br /> A L Z J4 `T U GQ <br /> HOME or MAILING ADDRESS FAX# <br /> 7 C-L ✓& ( } <br /> CITY,y-yil K L—tf STATYA ZIP '223b) <br /> 2 3 1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,, operator or authorized�agentt 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 F laws. <br /> APPLICANT'S SIGNATURE-��� _ DATE: Z , /7 - 2- <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZER AGENT❑ <br /> If 14PPLICRNT is not the BILLING PAR Tr 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 /> ar <br /> TYPE OF SERVICE REQUESTED: V QYI� I Y15 .Q R NT <br /> COMMENTS; <br /> �Ea l 2021 <br /> lifiv N RQNM NrUIV <br /> H DEA�TM�NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: IV S r2 ,! EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: L 0 PIE: UO3- <br /> Fee Amount: `C�c Amount Paid _ '1 Payment Date <br /> Payment Type '• /_ Invoice# ftwr--" 2-0 t q Received By: <br /> EHD 48-02-025 SR FORM (Golden Rad) <br /> REVISED 11I1712003 <br />