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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TacoG Tfarlo. S)Q00o3. <br /> OWNER/ORERATOR i <br /> Y n, rn� U Q— CHECK((BILLING ADDRESS <br /> FACILITY NAME Vim- - <br /> I C a S2x — Ch ctYe) Z <br /> SITE ADDRESS •? o, y <br /> G fiber Diralct'lon l Street Name — '1 C'Cil" 21)Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / q�-�-y Street Number -I LQ -r- eQ o-a <br /> CITY} 1t7 ( <br /> ! I STP�E ZIP d _ <br /> PHONE)#1 l• Exr APN# LAND USE APPLICATION IF <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR <br /> CHECK((BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex. <br /> HOME Or MAILING ADDRESS _ FAX# <br /> CITY 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, STATE <br /> �and <br /> dFFEDERAL laws. �7 <br /> APPLICANT'S SIGNATURE: �Y}7�.1`) ?S 1�/Y!� O DATE: GQ� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR T M ANAGER f OTHER AUTHORIZED AGENT L-1 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: MU CMIM RECEIVED <br /> COMMENTS: APR 2 6 2021 <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE; <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE; 311,11/E; <br /> Fee Amount: Amount Paid Payment Date L <br /> Payment Type Invoice# ck# 1 2 3 0 Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />