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DATE: ViLia72-1 <br />PERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST Pa D53652 / <br />Type of Business or Property FACILITY ID # <br />-?p\nEloo <br />SERVICE REQUEST # <br />siz 00S S'O°1 i <br />OWNER / OPERATOR OA owe.° Ss Us I att IristiviA_ CHECK if <br />afri s CZ. Cit <br />BIUJNG ADDRESSEE \I t I <br />FAaurT NAAIE <br />£3 <br />064.. (-1 <br />-Clekk}S Cae A te)e-Grea-on .--)A-Or <br />&MADNESS 1 (c 1 0 <br />Street Number Number <br />eris <br />Direction <br />QetrAeic- Pw-e_._ <br />Street Name Zip Code <br />54-co4rinn <br />City <br />HOME or MAIUNG ADDRESS (If Different from Site Address) c3coc, <br />Street Number <br />sAn tkollo(-4_3 EN._ <br />Street Name <br />CI STATE c TY <br />kir-ACkW \ <br />pi _ ZIP qs....)n ci <br />PHONE #1 Ea-r. ‘ <br />Oen) <br />APN 0 LAND USE APPUCATION # <br />Pa <br />102 ig En. , ;35v te SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR — <br />CHECK if BILUNG ADDRESS <br />BUSINESS NAME " PHONE # <br />( ) <br />En. <br />HOME or Mame ADDRESS FAX # <br />f ) <br />Cry STATE 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 <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: 1-tot3‘ PkAn. Wick_ RECEIVED <br />Commis: <br />emaktvolle e 3 m e x-i I , to k 7-- ) APR 0 5 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 1 .0404fi44D EMPLOYEE #: DATE: q_kv _al <br />ASSIGNED TO: EMPLOYEE 0: DATE: <br />Date SOTVICH Completed (if already completed): SERVICE CODE: Cj 2. 2) PIE: 40 I <br />Pee AMOUIM: 4 LAStp — Amount Paid s'•• C, fi Payment Date 1 4/4/2. I <br />Payment Type C. c Invoice # Check # <br />y <br />- i Received By: #1.--- <br />Lon 2 33q876/7