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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE VICE REQUEST# <br /> OWNER/OPERATOR �` •, �` CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME YJa '. JA`k O <br /> RGserno.c\e <br /> SITE ADDRESS WS ��S�.�ACt'l. �� SVOL�K�p /-\ 9S2'✓ / <br /> Sbaet Number Dlrecllon Street Name Cil ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slre¢INumber Street Nome <br /> CITY STATE ZIP <br /> 4�'� D r\ C. qs 20 <br /> PHONE#t EM. APN# LAND USE APPLICATION# <br /> (20)-L4�3-54gb9 <br /> PHONE#z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> CHECK If BILLING ADDRESS❑ <br /> -�)CA OIL 6ov <br /> BUSINESS NAME PHONE# Ent. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application an bat � to be ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an -•E aws. <br /> APPLICANT'S SIGNATURE: DATE: I I Z <br /> PROPERTY I BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IJ <br /> If APPLICANT s not the BILLING PARTY,proof of authorization to sign is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Mf` <br /> COMMENTS: 1veD <br /> -eln'Z4 !AN 13 2021 <br /> a.5N Q 1 nggG 719 C° GJGt Azo CO')-1 IAN JOAQUIN <br /> NEAL�7 p NME q�n <br /> i. ACCEPTED BY: EMPLOYEE#: 2T 1 DATE: ( I <br /> ASSIGNED TO: S EMPLOYEE O /_ ` DATE: t 13 Z <br /> Date Service Completed (if already ompleted): SERVICE CODE:rvP PIE: <br /> t Fee Amount: Amount Paid _ Payment Date <br /> Paymont Type Invoice# F In ec LJ �'2_Lf t2 Received <br /> J U <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />