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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PRD 53 61 &-7 <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> S ool �Ci�G4�e FRDbaa7BLi 11;1< 031930►�- <br /> OWNER/OPERATOR <br /> L1 hGO I� u111 1 c^ �C1„D„ Di ) 11t, <br /> � CHECK If BILLING ADDRESS <br /> FADIL TY NAME n �r t V S I.. O v 1 <br /> � em <br /> SITE,ADDRESS - Yin L✓, C./t't n 'II <br /> 15 Street Number Direction P�' ' `ar iL Name' 1 CI <br /> HOME or MAILING ADDRESS (If Different from Site Address) {{Qrr�sbu.r <br /> as5 Street Number Street Name <br /> CITY S' 1 _G1 /n ST�� zip 5 ^ ^—7 <br /> PHONE#1 ^�-� En' APN# LAND USE APPLICATION# (Y{J <br /> (000) C15a <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> r )' IM ` CHECK if BILLING ADDRESS <br /> n cv •O r <br /> v� 'N ale PHONE# Ex . <br /> Gil s 1�utri�' SexvicPS Lincoln n' )ed 5choo1 ,bjS�11& 95 -S(055 <br /> H o Ma iADDR�S n 1 C n FAX# <br /> I I C C.Q- 2J 14A- ( ) <br /> CITYStm Lynn STATE C L] ZIP qG <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 Coder,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ���� �a ,� � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAJOAGER ❑ OTHER AUTHORIZED AGENT® IS\'MC <br /> IfAPPLICANT isnot the BILLING PAR TYproof ofauthorization tosign isrequired Titre <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. WMENT <br /> TYPE OF SERVICE REQUESTED: - ri RECEIVED <br /> COMMENTS: DEC 18 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: 14 <br /> ASSIGNED TO: L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: nio <br /> P/E: W'2— <br /> Fee <br /> Fee Amount: 157— Amount Paid I sz Payment Date g 2 <br /> Payment Type C; Invoice# Check# 317.24 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />