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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REOUEST <br />Type of Business or Property <br />f�� pp�� o <br />✓'''T C/g5''^/�� <br />FACILITY ID # <br />SERVICE REQUEST # <br />CnmIA,ttr .i. Su. vmm� r%Q <br />PXONE# Exr. <br />94iAd5"3'7, 6s00 <br />HOME or MAILING ADDRESS <br />5 900 %"QI+Vt '!etre <br />OWNER / OPERATOR _. <br />Ht; L7V/40 qRn °q�Nry <br />FA>t# <br />(i°9 ) T3 <br />LV\ 0,CA IP t <br />CHECK it BILLING ADDRESS <br />FACILITY NAME <br />1--tVLr-a1Y\ <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: 6213 <br />DATE: 1-8-21 <br />ASSIGNED TO: Vidal Pedraza <br />SITE ADDRESS <br />G <br />EMPLOYEE#- 6213 <br />�larr15,pap <br />Date Service Completed (if already completed): <br />SERVICE CODE: 523 <br />Street Number <br />Direction <br />SI. <br />NameC <br />Payment Type ',<,_ <br />Invoice # <br />� <br />Check # )12CODZ <br />Recei ed By: <br />P Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE Zip <br />PHONE #t <br />APN # <br />LAND USE APPLICATION # <br />(�©4) 645�-rte 60 RgYYtd,te p <br />PHONE#2Ear. <br />(� ) J r B7 — 71`Q 1/32r <br />BOS DISTRICT <br />==CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUEST1O�R <br />V�v-1 <br />f�� pp�� o <br />✓'''T C/g5''^/�� <br />CHECK I}BIWNG ADDRESS� <br />BUSINESS NAME <br />a m <br />t <br />PXONE# Exr. <br />94iAd5"3'7, 6s00 <br />HOME or MAILING ADDRESS <br />5 900 %"QI+Vt '!etre <br />9 <br />Ht; L7V/40 qRn °q�Nry <br />FA>t# <br />(i°9 ) T3 <br />CITY Cerct, <br />STATE r!a�- Zip 7Q% <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, STA and FEDERAL la <br />APPLICANT'S SIGNATTJRE: 7 _ DATE: I 1) <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER❑ OTHER AUTHORIZED AGE.�IT WL (CN'1"YAL <br />JjAPPLxAAT is not the B/LUN(7PARTY. proof of authorization to sign is required Tttte <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. P �e <br />TYPE OF SERVICE REQUESTED: POOL remodel <br />h7C A, <br />,YD <br />COMMENTS: <br />SAN V 1? <br />Ht; L7V/40 qRn °q�Nry <br />T/y <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: 6213 <br />DATE: 1-8-21 <br />ASSIGNED TO: Vidal Pedraza <br />EMPLOYEE#- 6213 <br />DATE: 1-8-21 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 523 <br />PIE: 3602 <br />Fee Amount: 304 <br />Amount Pai <br />3 DD <br />I Payment Date / <br />Payment Type ',<,_ <br />Invoice # <br />Check # )12CODZ <br />Recei ed By: <br />EHD <br />48-02-025 <br />Payment confirmation # 119000249 SR FORM (Golden Rod) <br />1111712003 <br />REVISEDED <br />