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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> OA,LNO � 71 SQ yJ C)( <br /> OWNER i OPERATOR <br /> jr, / Tj AlnPPO A�i. CHECK If BILLING ADDRESS <br /> FACILITY NAME ✓ r'�s. <br /> TAG1J 00u5E kVVLcPrfJ 6&4L.k,-- ac � <br /> SITE ADDRESS LW-'-tai neo 9�' <br /> /h 9 95 Street Number Dlrectlon �" Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1119 v,4i fP(#-16 W4 Street Number Street Name <br /> CITY STATE ZIP <br /> 7rJt;V.1-00 t Ci SC 7 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (20% ) 7&5 54 1 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> (Z� ) <br /> 63b 9la- <br /> CONTRACTOR/ §FAVICE REQUESTOR <br /> REQUESTO <br /> y� ,, ^ 0 4 ��P CHECK if BILLING ADDRESS <br /> BUSINESS NAME��00 �\)cQr V l.!` ^ ^ �` P �655Li �� <br /> HOME,gr MAILING ADDRESS G `"` 1_' V FAX# <br /> LVOT 1; trR 1136 \S ` L ( ) <br /> CITY �r \L '�r-J STATE ZIP �JF. '�OtF <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. <br /> APPLICANT'S SIGNATURE: r �(C 411- �JdJ`f1 M t C DATE: <br /> PROPERTY/BUSINESS OWNERIf7/ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPL1CANTisnotthe B/LLtNGPAI? 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. WMENT <br /> TYPE OF SERVICE REQUESTED: C Oti Q� <br /> RECEIVED <br /> COMMENTS: <br /> AUG 19 2021 <br /> (7l/"" n�l I SAN JOAQUIN COUNTY <br /> I ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: WA/� A EMPLOYEE#: h DATE: <br /> ASSIGNED TO: ✓t EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Z SZ _ Payment Date 6z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 49-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />