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SAN JOAQUIN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 01a SunSe-I- Sweet) FACILITY ID# SERVICE REQUEST# <br /> wit Ari, l Cts 00 DOg 3 <br /> ONMERIOPERATOR 1 1 <br /> t/�y1S.t�1 acv, J <br /> Le 16 CHECK It BILLING ADDRESS <br /> 13 <br /> FACETrYNAME � �� <br /> ADDRESS— Street NuTnber D�- Eon "A \)L" Ro-eer N� Loa <br /> HOME or MAILING ADDRESS (If Dtrant mm Slta Address �,^ ` �� <br /> UCJ 1 Street Number cele ame , <br /> CITY Li n& ` STT ., `P S23 <br /> �I <br /> PHONE#t APN# LAND USE APPLICATION# <br /> PHONE#2 Ea. BOS DISTRICT LOCATION CODE <br /> Aa, ?LA (pa a. <br /> - - -i -. I --"CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR aM n S ( <br /> `C CHECKNBILLING ADDRESS� <br /> BUSINESS NAME PHONE# Em <br /> HONE or MALING ADDRESS FA%# <br /> CITY STATE IJP <br /> BH,LING ACKNOWLEDG NT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPAR•rNiEr, 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,Stand ds,STATE and F.RAL laa . <br /> APPLICANT'S SIGNATURE: �A DATE: G °l 0a <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AurnoRrzED AGENT❑ <br /> IJ'APPuraNT is not theSttttNGPatU•r proof of authorization to sign is required Tlrle <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 ENVIRONmENT'AL HEALTH DEPARTmBNT as soon as it is available and at the same time it is <br /> provided to me or my representative. DA <br /> TYPE OF SERVICE REQUESTED: R Ce� <br /> COMMENTS: , 0 <br /> SqN OCT 05 2021 <br /> ("�� p f /� N4Lr,'RpNMECCUNTy <br /> VV an C Q OVU I u SF�I( U I OEPgRTMF r <br /> ACCEPTED BY: , 1 EMPLOYEE#: ION <br /> N DATE: <br /> ASSIGNED TO: EMPLOYEE#: ( V sy DATE: f O fel <br /> Date Service Completed (it already completed): SERYICECODE• <br /> • 0(8 <br /> PIE: I UjD'1 <br /> Fee Amount "✓ .0 AmountPai <br /> /Sa,�� Payment Date �0 s <br /> Payment Type I ki�f- Invoice# Check# Received By: <br /> EHD 46-02-025 <br /> REVISED 111172003 SR FORM(Golden Rod) <br /> ._ VF,US40 fl-P <br />