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SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential <br /> OWNER/OPERATOR <br /> Daniel Galvan CHECK ifBILLINGADDRESS <br /> FAcauTY NME <br /> SITEADDREss 8675 Carey Ct. Stockton 95212 <br /> Street Number Direction I Street Name City Zip Code <br /> HcworMwuNGADDF;Ess (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH0 E#1 EXT. APN# LAND USE APPLICATION# <br /> (408 )393-7423 085-560-070 <br /> PFIOIE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVI CE REQUESTOR <br /> REQUESTOR <br /> t CHECK If BILLINGADDRESSE] <br /> BUSINESS NAME PH04E# EXT. <br /> C- S * Z29 - y�zy <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY IS <br /> �`/� ��v i STATE C,Vk 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 meor my business as identified on thisform. <br /> I also certify that I have prepared thisapplicati,o and that thework to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE an FEDERAL laws <br /> APPL I CANT'S SI GNATURE: DATE: l'/2' <br /> J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER ❑ OTHERAUTHORIZED AGENT ❑ <br /> IfAPPLICANT Isnot the BILLINGPARTY, proof of authorization to sign isrequired Title <br /> AUTHORI ZATI ON TO REL EASE I NFORM ATI ON: 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 /> 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. oft <br /> f p� <br /> TYPE OF SER AcE REQLEsTED: S� C . f e k )i, ' c,od 1V 1 c� F [-q[<e(1 n 51 u! l ®r/ <br /> Conm�ENTs: VieD <br /> APR 06 2021 <br /> SAN I/�AQUI <br /> HEAL DEPARTTAC <br /> ACCEPTED BY: _--:--l--7Z_ EMPLOYEE#: DATE: 9 ;/ <br /> ASSIGNED TO: A EMPLOYEE#: DATE: Ll/ 0 <br /> Date Service Completed (if already completed): SER MOODE. S � P/E �I wac <br /> Fee Amount: �,v� Amount Paid Payment Date Z/ <br /> 0 <br /> Payment Type Invoice# 2� 5 YI Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />