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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of B siness or Property FACILITY ID# SERVICE REQUEST# <br /> SR0083478 <br /> OWNER/OPERATOR <br /> 1�-N F Z Q (4( f� �I� ` L'�f CHECK If BILLING ADDRESS❑ <br /> Fa IUTY NAME 'l �4 <br /> t:.Fn ■ <br /> SITE A DRESS /44©,1 rt� -7 !` zlc <br /> Street Number Direction Street Name V L� Ci Zi•7Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT TPN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUS1N S2 NA+ S "OD-0 ` G••r(((� �I PHO E# ExT. <br /> HOME or MAILING ADDRESS �,}�, F / <br /> 'W Z.A.=�T <br /> CITU "y- STATE ./ Zip <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 1 have prepared this application and that the work to b erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard�ATE and FED L laws. Q / <br /> APPLICANT'S SIGNATURE:, / DATE: Z�IYl <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ e,0,4 . <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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �+��D,�� F �.;��''a:��� �`�r/�' : ��>.�� .� �/ �.. tom_�np�• . '' �� �. �..,�, <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE M 6213 DATE: 3-30-21 <br /> ASSIGNED TO: Vidal Pedraza EMPLOYEE#: 6213 DATE: 3_30_21 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P!E: 3602 <br /> Fee Amount: 304 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />