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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7Fa6� —t Z�)2 009H la <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME r1' vz,e� &, <br /> � Iu�Wl � t 1 Ir las <br /> SITE ADDRESS �✓ S lel I KStreet Number Direction `Ck1 \ b Stieet�ame 1a C ll���n 20 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SStreet Number StrNam¢ <br /> CITY y O Q l-i CA STATE zip zo <br /> PHONE#I Em APN# LAND USE APPLICATION# <br /> (70-P <br /> PHONE#2 EXr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR oat <br /> a-'��� �T� r\ CHECK if BILLING ADDRESS <br /> BUSINESS NAME `K l ` Z1G,✓� PHo� En <br /> r � r1 v - 2 <br /> HOME or MAILING ADDRESS 6 "I ^ FAX# <br /> CITY G 1 w. _ t STATE(!A— zip <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 JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: M C9 Ir 1 C.Q Yk O ('`` �t)Z. Aa k DATE: G t///� Q�?O Z T <br /> PROPERTY/BUSINESS OWNEOR OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ffAPPLiCAfT is not the BfLLL?VG P.4R 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 envi sessment <br /> information t0 the SAN JoAQuiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabla time it is <br /> provided to me or my representative. RECE <br /> TYPE OF SERVICE REQUESTED: nrT 2 S 2021 <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE; v <br /> ASSIGNED TO: ""� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 2 <br /> Fee Amount: Amount Paid 1W Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />