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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R 05 1 �l <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR <br /> E/Zdl.�IN�E� CHECK if BILLING ADDRESS ff <br /> FACILITY NAME <br /> LOS <br /> S S /1 S fI Ds � 2�2 f/ <br /> SITE ADDRESS �� V t • /rjJ�l (;..1/! f aO� hJ�n qSi)i•�2 <br /> Street Number Dire on CA l•ll" tl Streel Name CTTtt /V 2I�ootd/e✓ <br /> HOME or MAILING/AD,�pDnnRE��S�.S (If Different from Site Address) <br /> 1 S /�� <br /> tel e `Tifx- e / GCJ Street Number Street Name <br /> CITY 6,00� C S�,A�E zip /Jsr[�D <br /> PHONE#1 E'rT• APN# LAND USE APPLICATION 7 <br /> 6' <br /> �2N`�rt) Gyl — 620_ I EM• 80S DISTRICT <br /> LOCATION CODE <br /> V %TCONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` ^ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME /OS S -G S PH�# 1>/ el ` Q�ExT. <br /> HOME Or MAILING ADDRESS FAX# 7 Y <br /> 151 S-( C N42tieq C AJ ( ) <br /> CITYCO D STATE ZIP qs t ela <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 at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S a FED L laws. <br /> —APPLICANT'S SIGNATURE: ---<� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPL/CAA"f is not the B/LL/NG PAR7T 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 the or my representative. T <br /> TYPE OF SERVICE REQUESTED: o `�V►' 1 U. ED <br /> COMMENTS: <br /> MAY 0 3 2021 <br /> SAN JOAQUIN I OUNTY <br /> ENVIRONME NTAL <br /> HEALTH DEPA TMENT <br /> ACCEPTED BY: r I r " S EMPLOYEE M QS -30 DATE; - 'Z/ <br /> ASSIGNED TO: t ( EMPLOYEE 3CPI DATE: 3.721 <br /> Date Service Completed (if already completed): SERVICE CODE: f P E: I LPD3 <br /> Fee Amount: ,O Amount Paid 1 (!92 Payment Date <br /> Payment Type Invoice# Check# Received <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />