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`r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />► SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />c <br />I vGD <br />MAY 15 ?020 <br />H f�RONINOOUN <br />fALTy 0E m Arr 7Y <br />ACCEPTED BY: <br />W'�>7001© <br />OWNER/OPERATOR <br />CHECK If BILLING ADDRESS <br />�cI <br />L' f u", A <br />_, <br />FSE 1 <br />PHG # ; _ 1 S EXT. <br />a�CA I <br />VI l <br />PIE: ' v <br />Fee Amount: <br />SITE ADDRESS/' <br />-' �Ci <br />.E . od, pvc <br />.tcrl, u, <br />�52yU <br />street rvum nor I Dim I <br />Street Name <br />CIty <br />zip Cotle <br />HOMEDr MAILING ADJJPP/f2E (if Different from Site Address) <br />�� <br />lIJ <br />Street Number <br />Street N4me <br />CITY <br />D <br />STATE ZIP <br />o <br />PHONE#f ExT• <br />APN# <br />LAND USE APPLICATION# <br />- q2 5055 <br />PHONE 92 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE ESTOR <br />I /I C (� <br />�C' <br />COMMENTS: 6111 Z4A-> �AJ,r y�y L�'/�'lr '� `�� <br />ON I FpaVL-n <br />c <br />I vGD <br />MAY 15 ?020 <br />H f�RONINOOUN <br />fALTy 0E m Arr 7Y <br />ACCEPTED BY: <br />f /1 G G 0 <br />victoiG <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEO <br />_, <br />PHG # ; _ 1 S EXT. <br />a�CA I <br />t <br />PIE: ' v <br />Fee Amount: <br />HOME or MAILING ADDRESS <br />`` <br />Payment Type <br />FAx# <br />Check # <br />I Received By: <br />CITY L > <br />STATE a ZIP qJ 2 t <br />BILLING ACKNOWLEDGEMENT: 1, 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 applicati ri and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />- <br />COUNTY Ordinance Codes, Standards, STAT I FEDERAL laws. + <br />APPLICANT'S SIGNATURExZ4?1 <br />DATE: ` S '2U 20 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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: -006( ?[(WAki CA4f - <br />�C' <br />COMMENTS: 6111 Z4A-> �AJ,r y�y L�'/�'lr '� `�� <br />ON I FpaVL-n <br />c <br />I vGD <br />MAY 15 ?020 <br />H f�RONINOOUN <br />fALTy 0E m Arr 7Y <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />^ <br />ASSIGNEDTO: J, yi C� /J� t' <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:j Z � <br />PIE: ' v <br />Fee Amount: <br />Amount Paid <br />Payment Date 5 I S 2(0 <br />Payment Type <br />Invoice # <br />Check # <br />I Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />?� n;q" 90 5 <br />