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c SAN JOAQUIN COUNTY ENVIRONMFNTAI III v,rH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r�,�� -�uran�' 1=(A 000 12 �q L( Ga Coi31Q(Q�j <br /> OVYNER �PE4"TOR <br /> S-L� � CHECK If BILLING ADDRESS LJ <br /> FACILITY NAME I_ _ f <br /> /LC- <br /> SITE ADDRESS A-Y C �i7L c< L l- <br /> l0 vc 7t <br /> Street NUmIHr DI ilon Street Nema C D <br /> p r.J4 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> S~.M Number Streat Nemo <br /> CITY STATE zip <br /> PHONE#1 En. APN M LAND USE APPLICATION 0 <br /> (20`1 ) 201-A33� 2351103\� <br /> PHONE 02 Exr. BOS DISTRICT LoclffvDE <br /> 120 13aI-54i�I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTER SII <br /> l� 1 CNECKNBILLING ADDRESS <br /> BUSINESS NAME I t.L�G P D� Et <br /> HOME or MAILING AD FAX# <br /> ?)aC-�- yA 1 ) <br /> CITY Sly LP !�—7 <br /> BILLING ACKNOWLE GEMENT: 1, 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 /> 1 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,StandarSTATA } <br /> E,,and <br /> -�FE L laws. <br /> APPLICANT'S SIGNATURE: _ ' DATE: 12-1 Z) <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ 0THERAU'EI0RI7YDACENT11 <br /> /JAPPLICANT LT not the B/LL/NG PARTt'proojof author$ation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> infornlalion 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 <br /> TYPE OF SERVICE REQUESTED: oa-w-k ` \ L Re, <br /> COMMENTS: <br /> MAY 0 5 WQU <br /> 2021 <br /> y DfPgRMAL <br /> ACCEPTED BY: ,���f EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1-\ r.e c, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: L-)b 1 PIE: , b 02 <br /> Fee Amount: I S 2- — Amount Paid 1 5 2 — Payment Date 5 - 5 - 2- <br /> Payment Type C L Invoice# Check# Received By: <br /> EHD 48-02-025v 1 2 y t7 C) I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 f Ic-t)l�l W V 3 S <br />