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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> *ver USS /I CHECK If BILLING ADORESS� <br /> FACILITY NNAME V ]'� <br /> SITE ADDRESS J{(� C p}� I oet <br /> / V Street Number I Direction "` treat Name 1C/ •S� cityo e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IG <br /> ry I,v r ,�ro <br /> !y (. `/W tT�( CHECK If BILLING ADDRESS <br /> BUSINESS NAME r� L ��O/ 1 l�S t-- �n PH NE# EXT' <br /> HOME �MAILING AD12RESS FAX# <br /> CTU O a 7n&y C ( ) <br /> CITY - STATEC ZIP - ; <br /> 26Y, 14 <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 Codes,Standards, TATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> ` 0/-0� — -2 <br /> PROPERTY/ OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENr'4l, CwaC�aY' <br /> IfAPPLICANT is not the BILLING PARTYproof of authorization t0 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. I <br /> TYPE OF SER CE ESTED: �YYV vl <br /> COMMENTS: 91 <br /> 2020 <br /> k3� <br /> SANO <br /> COUNTY <br /> ENVIRONMENTAL <br /> ENTALENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: v,{ EMPLOYEE#: DATE: Z(J <br /> ASSIGNED TO: I �) EMPLOYEE#: DATE: W 2 <br /> Date Service Completed (if already completed): I' SERVICE CODE: P 1 <br /> Fee Amount: Amount Paid o Payment Date LQ <br /> Payment Type Invoice# Ch cert# b Received BJ: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �ouL �►2_o3lt��IB <br />