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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �� �✓f S� n'S 7q <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS IJ�7y� IJ !S ZO <br /> t �3 <br /> Street umber Dlrecllon [reel Name Cit ZI Cod¢ <br /> HOME Or MAILING ADDRESS (if Different from Site Address) Y2-13 n��( C La <br /> _ I n n <br /> Street Number /" /Strtreet Nla✓meF <br /> CITY Moo-e S 1v STATE ZIP 4✓ 3 <br /> ' PHONE#t ERc APN# LAND USE APPLICATION# <br /> (201 ) �3- /tig6 <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> O CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> t <br /> l- Q �S ( 0 `tS3 <br /> HOME r2M/ILLIING ADDRESS. FAX# <br /> 7 A4, / ( ) <br /> CITY O n„ IF STATE C4 ZIP ns/ <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 appli'C015'an—li3hat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, SATE and ERAL aws. <br /> APPLICANT'S SIGNATURE: DATE: 3/I(P/2 �y <br /> L---PROPERTY/BUSINESS OWNERS TO OP MANAGER ❑ OTHER AUTHORIZED AGENT❑ J)fLe�I 'pw.a <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 /> TYPEEQUESTED: TEA S n p <br /> le <br /> .— p <br /> 6 2021 MAR 16 2021 <br /> tYtAg 1 ENVIRONME <br /> SAN JOA oNMEN p1. 1 �T PERMIT/$E y DESALT <br /> A&a'r�n Y: ✓�` �I S - <br /> EMPLOYEE#: Y �G DATE: <br /> ASSIGNED TO: I v l EMPLOYEE#: D DATE: -3 ,L /L <br /> Date Service Completed (if already competed): SERVICE CODE: P/E: 3 <br /> Fee Amour N. 1!5`� Amount Paid 5 a / Payment Date 31 a <br /> Payment Type Invoice# Received By- <br /> EHD 48-02-025 s--�� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �'fLOMl05°l� <br />