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SAN JOAQUIN COUNTY ENVIRONMF,NTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILrrY ID Y SERVICE REQUEST A <br /> /3�,VNU&7 -f 12'\ <br /> OWNER I OPERATOR CHEM If BILLING ADDRESS <br /> JOSS S4 <br /> FActLm NAPE <br /> SITE ADDRESS /Q05 (. /7�S�A-7 C,ZO1�,f �,C <br /> StrW Num GI s / e <br /> HDPE or MAILING ADDRESS III DlReront from Slle Address) 9/ <br /> fity"I Him <br /> Cr STATE Z P <br /> _cL <br /> PRM Y7 , .l�*• I I APN a UwD USE APPUCATION e <br /> (,2A) <br /> PHOME02 En. BO$ptsTAleT LocATroN CDDE <br /> 1 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CNECKN BILLMG ADORESs <br /> BusTNEss NAME <br /> P wNE Y ' <br /> HOME or MAIUNG ADDRESS FAx Y <br /> 1 1 <br /> Cm STATE ZIP <br /> BILLING ACIGNON•LEDGENEIIT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> ack toe9edge that all site and/or project specific ENVIRONMENTAL.I IEALTII DEPARTstENT hourly charges associated with this project <br /> or activim,will he billed to me or mY business as idemired on this in lm. <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 /> Cou%-n'Ordinance Codes.Standards.STATE and FEDERAL laws. 11 % <br /> APPLICANT'S SIGNATURE: / '.- —� DATE: <br /> J�amI, , <br /> PROPCRT'I CSI\'[GSD%INERL'J DrERATOIt/\Lt N,\(II:R ❑ OruEn AtrrtIOw-EI)AGENT❑ <br /> rrLJCZ7(sootrheRnl,Ar,P.IN7lpro)fofneTltorfzarionrosignisregtrired Tilt, <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 environmentallsite assessment <br /> information to the SAN JOAQUIN CourriY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is availableal the same time it is <br /> provided to me or my representative. -'AY <br /> TYPE OF SERVICE REODESTEO: IIECEI V <br /> COYMEWS: MAR 12 <br /> 2021 <br /> SAEN JOACOAL <br /> i HEALTH DERARTbIENT <br /> AccE"EDBY: L� n1^���� EMPLOYEEM t-AS�� DATE, <br /> AssioNErsio: L EMPLOYEE Y: -1 SU DATE <br /> Date Service Completed (Ir already complated): SERVICE CODE: 0101PIE: <br /> Fee Amount. S 2 Amount Pa / U� Payment Date 3 Z <br /> Payment Type C Invoice 9 Check NRevel By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172009 � I <br /> Scanned with CatnScanner <br />