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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �A =32� SQ oog&a 4- <br /> OWNER/OPERATOR <br /> 1;/?' <br /> (�bJi�rA L/��� ' CHECK If BILLING ADDRESS E] <br /> l <br /> FACILITY NAME 1 "Ro \ q, � VdAvkow1- <br /> SITE ADDRESS P'l C�-5 I M k A C��-, <br /> Street Number Direction I Street Name v v'City`+ Zi Code J <br /> HOME Or MAILING ADDRESS (If iffere t from Site Address) <br /> `V S C'f t Street Number Street Name <br /> CITY (SA <br /> STATE ZIP <br /> �C ll� (Ot^ CJ1 S V <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION III <br /> (Sk0 ) g-4- SgRo`L <br /> PHONE92 Ezr. BO$DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS/ <br /> Vic(Scz). CnL <br /> BUSINESS NAME L`A �� „n�n x&544 _- Q, PHOiE -79✓ 5102 <br /> HOME or MAILING ADDRESS ^ ' 1 r t '�RK. rn t� �U^'It�'�/� FA%# L <br /> O/` V` ( ) <br /> CITY STATE Zip aS�S <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 t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE andPo <br /> g_wS. <br /> APPLICANT'S SIGNATURE: DATE: 1i 1t0 7/I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR(/M'XNAGER 11 OTHER AUTHORIZED AGENT❑ <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: TW <br /> COMMENTS: E® <br /> FEB 16 2021 <br /> JOAEIWIRpbt N COUN <br /> HEALTH DEPMENTAt 71 <br /> "TrP610- <br /> ACCEPTED BY: EMPLOYEE#: DATE: (n r7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: Li <br /> Date Service Completed (if already completed): SERVICE CODE: J PIE: 1 (06L I <br /> Fee Amount: t. ,�. Amount Pai (s-2 Do Payment Date `� z <br /> Payment Type Invoice# Check# /�' 3�' D Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />