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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type'of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r10 �� S12GUg3 C�� <br /> .OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACII-7 NAME Deb <br /> I / <br /> SITE A 752 <br /> DDDRESS <br /> ) / //`,/J/jd� ' <br /> f / Street Number Q.e-ion ! //L� eet Name ((Jam" <br /> HOyll or MAILINGRESS (If Different from 'te Address) <br /> �1\ Street Number Street Name <br /> C1 STATE zip <br /> C� <br /> PHONE#1 fir• APN# LAND USE APPLICATION# <br /> ONE{#2� <br /> 37 l <br /> BOS DISTRICT LOCATION CODE a . - o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR % <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEP�gNE# Em <br /> De TxLLi O LA (GO ) S <br /> HOME Or MAILING ADDRESS FAX# <br /> L1 2 ( ) <br /> CITY : 57/ STATE CA= <br /> 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 I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard ,,k TE and FEDERALlaws. <br /> PPLICANT'S SIGNATURE: DATE: <br /> ��jj- <br /> PROPERTY/BUSINESS OWINERy41_ P RATKOR/ ❑ OTHER AUTBORizED AGENT EJ <br /> If,IPPL/CenT is not the !LL/NG 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. p r <br /> TYPE OF SERVICE REQUESTED: �E`+ <br /> COMMENTS: rf&G{�J C r o,��reY� JUN <br /> 16 2021 <br /> SAFI UO <br /> OUNTY <br /> H� DEPS NT <br /> ACCEPTED BY: \ C V EMPLOYEEM DATE: (Aha <br /> /7 / <br /> ASSIGNED TO: 1 J EMPLOYEE#: '2 DATE: l& u /20 <br /> Date Service Completed (if already completed): SERVICE CODE: f p 11 E: <br /> Fee Arnount: r /1 Amount Paidra / Payment Dae /^//CO2 <br /> 1 �.r' <br /> Payment Type OPI9 I9 0'4eV Invoice# Check# I Received By: dlu/M <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />