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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SRACE RACE REQIUEST# <br /> T l� �l� /hCJ JOO�-1151�K <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> '(91 <br /> FACILITY NAME" I _ <br /> /" Ccttel-in L lC WcZS �/.� <br /> SITE ADDRESS s GGP l�OC/7/ GL S'-t StOc(C fC/? <br /> --:?('�� Street Number I Direction Street Name CIN ZIp Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> G fl 9"5.231 <br /> PHONE#1 Eay. APN# LAND USE APPLICATION# <br /> (Zu7 ) 26 - 655 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NNAME ! vl a .PHONE# Enr. <br /> 5 i i B / <br /> HOME Or MAILING ADDRESS FAO(# <br /> ti . FM <br /> CITY U STATE // ZIP q">Z3/ <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 Colles,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: w!( Gf DATE: 121 K A2l <br /> PROPERTY/BUSINESS OWNER❑ OP OR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <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. <br /> TYPE OF SERVICE REQUESTED: e hcrf S e` IAA/"-- <br /> COMMENTS: -WACD <br /> �,11G1 Vl� 0 pWV�P/��lA/� DeC 06 2021 <br /> RO�INCOU <br /> ��IGtyQ��Ntq�ry <br /> M <br /> ACCEPTED BY: I t� EMPLOYEE M DATE: <br /> ASSIGNED TO: 1�n - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: `�1 I P I E:'' lDn <br /> Fee Amount: I�Z Amount Paid ' (tea� Payment Date 2 <br /> Payment Type Invoice# e5tReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />