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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# /SERVICE REQUEST# <br /> 1?.>? 5 alArc r �� S�UUB A <br /> OWNER/OPERATOR <br /> 06600 CHECK((BILLING ADDRESSO <br /> FACILITY NAME <br /> Sn ADDRESS q6&3 1"cC t� i G AUC- 14 D '-incl tan g 5 Z o 7 <br /> Sueet Number Olre'e Street Nama C ZI Code <br /> HOME or MAILING ADDRESS (N Different from Site Address( S�, <br /> uAyfPlu� <br /> Stnet Number /'(+p St et Name <br /> A.1I�� <br /> CITY GCc' Sl- 1'I zip 95-331 - <br /> PHONE#1 1_1. Ev. APN R LAND USE APPOCATIDN N _l <br /> ( Z0'1 I IDLl9- S Z.LLo <br /> PHONE12 En• BOB DISTRICT LOCATION CODE <br /> ( i <br /> CONTRACTOR / SERVICE REQUESTOR �rsy <br /> REQUESTOR /1 1c" AGA f coa CHECK If BILLING ADORESS a� <br /> BUSINESS NAMEAK.EA If-16 <br /> � E>ti• <br /> 5 <br /> HOME or MAILING ADDRESS q FA%# <br /> �S F-la rvwn 5'r ( I <br /> CITY Il J�C� �C C c_ STATE ZIP Gl J3 3 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this application and that the work to be performed will be dune in accordance with all SAN J0A011lN <br /> COUNTY Ordinance Codes,Standard ST TE and FED AL awS. <br /> APPLICANT'S SIGNATURE: DATE: 1'11211 /2 l <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER It OTHER AUTHORIZED AGENT E3 <br /> IfAPPL1CANT is not the BILLING PARTY proof of authorization to sign is required Tille <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby allLhorizc the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTif DEPARTMENT as soon as it is available and at tlyC same timC it is <br /> provided to me or my representative. Nq <br /> Lkz-Iry <br /> TYPE OF SERVICE REQUESTED: =vt 3�E C.1't o✓1 CE <br /> COMMENTS: ZY,sped to,j -Vo ab�r-I n !4eGAn sq JAN OS 202 <br /> Hf jC <br /> L�OpNMECOU 7 <br /> EPgRTMENT <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 1-5-22 <br /> ASSIGNED TO: Vidal Pedraza EMPLOYEE#: 6213 DATE: 1-5-22 <br /> Date Service Completed (ifalready completed): SERVICE CODE: 061 PIE: 1602 <br /> Fee Amount: 152Amount Pa Payment Date 2 <br /> Payment Type �SA- Invoice# Check# 3 kol90 -z 1 Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ?f'b' q <br />