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A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 0c)-zs1 -97 -�- 5Q + 0V—+-05 <br /> OWNER/OPERATOR 1 <br /> �1tiI l s e{ o Pe -Je S�C Oq(�, n vb%— CHECK if BILLING ADDRESS O <br /> FACILITY NAME 6Yv'Q(f,+ -* —1 1 WZ JA'1. Lv <br /> SITE ADDRESS 32-1 F 1 K L` _ A _ ^1-- 1G, " ' S <br /> Street Number Olr¢ction Street N¢ma �T LL.tci W" V Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 321 JE WA-) s,l --Z �-fg 41S <br /> Street Number �.l"" Street Name <br /> CITY I'L �\ STATE l,/�^ „ ZIP <br /> 7 ' <br /> PHONE#1 En* APN# LAND USE APPLICATION# <br /> (2m ) 2'-f 2- t0(Q(O'-I <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 ��/ CHECK If BILLING ADDRESS <br /> U, sr, �1lL l � 17� e�SuS - C�SJ-vi rr�oL� <br /> BUSINESS NAMEPHONE# En. <br /> 5vJ,2�1- * -3"7 3 t41 V 'L <br /> � ( 9-N 2-L9(e(1P <br /> HOME or MAILING ADDRESS 19 FAX# <br /> CITY ,h;)*4,::r v STATE 04 ZIP Iq -� <br /> BH,UNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborized 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 Coder,Standards,ST ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 01 ^( 0— 2 2- <br /> PROPERTY <br /> PROPERTY/BUsiNEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL1CtNTisnollhe BILGINGPAR7Y 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.. I_ <br /> TYPE OF SERVICE REQUESTED: ( JP/Vhl( Q �.bV�'l.l.Vhtl�ts�-RECEIV <br /> COMMENTS: Gkar^L� ���G v n Ad o L J 5'?3 L1I w-z JAN 10 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> .^ HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O/ „ I PIE: U <br /> Fee Amount: (� L�Z Amount Paid ��S Z Payment Date '//0/2-, v2— <br /> Payment Type Invoice# Check# Received By: <br /> EHD 25 j d 0 SR FORM(Golden Rod) / <br /> REVISEDSED 11 11/17/2003 <br />