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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 120� 4IN <br /> OWNER/OPERATQft <br /> ![OM r//Ltd. CHECK If BILLING ADDRESS <br /> FACILITY NAM!p.,�y�_�(�'Y-�i <br /> SITE ADDRESS 4F (K 'Z Z�i¢�. �, t1A m LAl_e c(,n 177✓l qJ a/r7 <br /> G <br /> Street Number I Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Oft /B -,Z1/ /�• <br /> 117 t <br /> Street Number Street Name <br /> C U/46k4K // ZI�It �D <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> (,off <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUf�,ssTOR CHECK if BILLING ADDRESS <br /> r40 <br /> BUSINESS NPHONE# EXT. <br /> t'l Ca PL`( 9P/- 2 <br /> 1 <br /> yZ <br /> HOME or MAILING ADDRESS FAX# <br /> 1,921 <br /> CITY /?'L cn STATE (� ZIP G1rej�C� <br /> BILLING WACKNOWLEDGEMENT: 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,ST TE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: B�tU�2dl <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILL1NGPART Y 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 environmentaVsite assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availablebpd at the same time it is <br /> provided to me or my representative. PA <br /> TYPE OF SERVICE REQUESTED: �5�,Ibin cei <br /> COMMENTS: AUG <br /> UV O 2021 <br /> HMflROUIN COUNTY <br /> HEAL7I DEp�M NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ZD 21 <br /> ASSIGNED TO: ( W EMPLOYEE#: l / DATE: 7I <br /> Date Service Completed (If already completed): SERVICE CODE: /� P I : _ly <br /> Fee Amount: Amount Paid l��' Payment Date 8 20 <br /> Payment Type Invoice# e `3�( j��j �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> PRoS�� t�S <br />