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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5R00'? 3�so <br /> OWNER i OPERATOR, <br /> Ly CHECK If BILLING ADDRESS <br /> FACILITY NAME ! 1 L �l G• G-70 _ <br /> SITE ADDRESS U C S t�A't /�,}/- S /{(�' ((M./(20('L('o <br /> 2 5 Y�pmber Direction / r` O' ` Street Name Cit Z Gode <br /> HOME or MAILING ADDRESS (If Different from S'te Address) <br /> S `( OT e Street Number Street Name <br /> CITY ^ OL V\, AL-el-C a STATE„ q ZIP (�3 3 <br /> PHONE#1(-1-o I ExT• APN# LAND USE APPLICATION# <br /> (gpa) & 7 -3-99C ?- <br /> HONE#1 <br /> EKT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> cn e, Z CHECK II BILLING ADDRESS <br /> BUSINESS NAME PHONE# �T• <br /> HOME Or MAILING ADDRESS �� Qr� ( ) <br /> AX # <br /> 25/ < Ore ah S p (-- ? <br /> CITY HlGn,he-C-q STATE ea• zip l JU <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,STATE and FEDERAL laws. / / 1 <br /> APPLICANT'S SIGNATURE: 9t 10, vt e 9( /\ 'L' DATE: <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> 1f APPLICANTisnotthe BILL/NGPARTY 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: REECEIVED <br /> COMMENTS: <br /> JUN 14 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ri'l DATE: (/ <br /> ( �/ <br /> ASSIGNED TO: /1 EMPLOYEE#: DATE: 1(// <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: I 3 <br /> Fee Amount. l;2 00 Amount Paid SZ _ Payment Date Z' <br /> Payment Type L V.. Invoice# eck# Z L o p o7� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />