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SAN JOAQUIN COUNTY E?,NIRONMENTAL HEALTH DEPARTMENT X/ T'2• 'J <br /> SERVICE REQUEST pfl b l� 3 3 Ll 8 <br /> Type of Business or Property FACILITY ID# RVICE EEWESS% <br /> Lo ion Fh- 0c) 150/0y 6 ✓✓ ffll.. <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAOuTY NAME ` <br /> G412s J / ' �Ii 1 <br /> SITE ADDRESS ,(/3/ pa'-/r7c 41le C'7!ke-I< -D Yt c6r167 <br /> Street Number Direction Street Name J Cityr L Cade <br /> HOME or MAKING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 Ea. APN# LAND USE APPLICATION# <br /> PHONE#2 Ea. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# /J -7 EST. <br /> % O - <br /> HOME OrRULING ADDRESS 6 <br /> /3/ 9aC,; 6 Ave FAX# <br /> CITY S O CI� i a Jul STATE C•(�/ zip 015 07 <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 ENVHtONMENTAL 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 FEDERAL laws. J <br /> APPLICANT'S SIGNATURE: 14 DATE: 3 / a oZ ' l <br /> PROPERTY/BUSINESS ON'NERM, OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPPLICANT is not the BILGING 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 COILTNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C Jq` d-r— $ <br /> REG EIVEE D' <br /> COMME <br /> RECEIVED <br /> MAR 2 4 2021 +ah ir' 6a he, w/ e 9m,�ul 601?l MAR 2 4 2021 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> CES <br /> Acca ]<{DE A EMPLOYEE <br /> ASSIGNED TO: W EMPLOYEE#: 3 (P 1 DATE: 3 //� 24 <br /> Date Service Completed (If already completed): SERVICE CODE: pi : 'l,l�VZ <br /> FeeAmount: Ak •00 Amount Paid/- ls02 n Payment Date Z <br /> Payment Type Invoice#n y� Check# Received By: <br /> EHD 48-02-0n�-1I NA I'l`r025 WS� SIR FORM(Golden Rod) <br /> REVISED 11/17/2003 —O <br />