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SAN JOAQUIN COUNTY ENviRONMENTAL RFALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::::I Sgo8iAqq <br /> OWNER/OPERATOR <br /> trek K'Aer(7 CHECK if BILLING ADDRESS El <br /> FACILITY NAME C . �e i ee I, sbcl u Ic <br /> SITE ADDRESS r 1 e <br /> C+C. <br /> Street Number Direction CGt /tr\eet Name Cllt (JZip Cod. <br /> HOME Or MAILING ADDRESS If Di rent from Site Address) „_/ /' v C 1 <br /> oc Street NumberSt'r1e-aTliNa/me l <br /> CITY L C0\19 I STAfEn ZIPS S Z yZ <br /> PHONE#1 °Y EXT, APN# LAND USE APPLICATION# <br /> tZoS) ��O -aZ$g <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/,SERVICE REQUESTOR <br /> REQUESTOR Is <br /> k ,–) <br /> _r <br /> ( I <br /> 1 Y� CHECK If BILLING ADDRESS <br /> BUSINESS NAMES i�e j- S� � 1�� PNOxt)NE# X*�to Z� E <br /> HOME Or MAILING ADDRESS 2 / /'� J FAX# <br /> (2cC rt-CJ'1� 1,7' ( ) I' <br /> CITY /-00) STATE(' ,[j ZIP z y Z <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,Stan and FEDERAL laws. / <br /> APPLICANT'SSIGNATURE:�' DATE: '71-2- 2-0Z <br /> PROPERTY/BUSINESS OWNER ~ <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ c-)�r <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, geotechtucal 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: M-M, 16 Tnal i n <br /> COMMENTS: /I�w <br /> APR 022021 2 ?021 <br /> SAN <br /> gAVIRQUIN CO <br /> HEALTH p p'NENTgi <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE; Z y) <br /> Date Service Completed (if already completed): SERVICE CODE; 0LpJ I P/E: r(/05 <br /> Fee Amount: Amount Paid 15 / Payment Date <br /> Payment Type Invoice# ✓ t a Received By: <br /> EHD 48-02-025 SR FORM(Golden.Rod) <br /> REVISED 11/17/2003 <br />