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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property AQI.ITY IDD## SERVICE REQUEST## <br /> toP <br /> OWNER/OPERATOR <br /> VVI`.... 4\}01 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS '�Ti�l!✓ �G I` �N, ��C��� <br /> SStreet Number Di5lion ItyZi Cotle <br /> HO E r MAILING ADD SS (If Different from Site A cess) <br /> I - S street Number Street Name <br /> CITY GK s � zI!� 5�3 <br /> P EXT' APN# LAND USE APPLICATION# <br /> (;:-I ) <br /> PHONEW2 Ea. BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i I' tTXI ` CHECK if BILLING ADORESSO <br /> BUSINESS NAMEI /-^ l' PH E# Ea. <br /> $38 7qqq <br /> HOMF�Or MAILING ADD SS lL V FAX# <br /> S z I ( ) <br /> CITY ST ZIP Q7 <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 FED laws., <br /> APPLICANT'S SIGNATU DATE:�/ /7 <br /> 2 <br /> OPERTV/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTis not the BLLLINGPARTY 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: PoLani <br /> COMMENTS: <br /> NOV 17 ?021 <br /> SAN JOAQU <br /> NWRONIN CUN ), <br /> ^ �iA p EAL171 pFp4SI� <br /> ACCEPTED BY: I i EMPLOYEE#: r� DATE: <br /> ASSIGNEDTO: I' 0e4 E , EMPLOYEE#: 3311 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: D( ol /E; f 0 3 <br /> Fee Amount: f 00Amount PaId4D Payment Date I Z <br /> Payment Type Invoice# Check# Received By: <br /> Wly- <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 ^�l45o <br /> W V <br />