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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fiwr�TF PrO()0 -4-2bi S SD�v <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ,JAVA <br /> S HAI <br /> HAI FLN�:1bLif'rr <br /> SITE ADDRESS ¢� <br /> JJBStreeNumber Direction I Street Name / <br /> CrSZ�Ca e <br /> i <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> (r{1 yS Street Number Street Name <br /> CITY SCTATE qP' <br /> PHONE#1 Exr' APN# LAND USE APPLICATION# <br /> (N IV) 602 CSl2 <br /> PHONE#2 En, <br /> 2- © S12- BOS DISTRICT LOCATION CODE <br /> - b� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exs <br /> HOME or MAILING ADDRESS FAx# <br /> ( 1 ! <br /> CITY STATE ZIP r <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 F S. <br /> APPLICANT'S SIGNATURE: _ DATE: III 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is Not the BILLflVG PARTY 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, <br /> TYPE OF SERVICE REQUESTED: G�pv\ �'}�)�r'��� PAYMElyr <br /> COMMENTS: RECEIVED <br /> NOV 19 2021 <br /> SAN JOAQUIN COUNTY <br /> HEALTH ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: C7 DATE: <br /> ASSIGNED TO: ^ v _ ` EMPLOYEE#: `��15of DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: OI_ I PIE. k bV o`, <br /> Fee Amount: 'S Amount Paid �5 Payment Date 2 G.. <br /> Payment TypeaInvoice#go 1 4 1-5-qM10/ Received By: <br /> EHD 5 SR FORM(Golden Rod) <br /> REVISEDSED 11/11!17/2003 <br />� 1 <br />