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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />::A <br />FACILITY ID # <br />S RVICE REQUEST # <br />ACCEPTED BY: V`fLA e S C-4 <br />_ <br />S(KbO%S'?" <br />OWNER/ OPERATOR r, <br />Nwkyy <br />CHECK If BILLING ADDRESS <br />FACILITY NAME t E C <br />knpeA V1 <br />SITE ADDRESS <br />` \ <br />\1 <br />\ <br />�q�✓7y��� <br />1 <br />G`C���/_ <br />yi <br />1 Street Number <br />Drectlan <br />�^'ll/t <br />eet ame�6 <br />1 CI <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />I3 <br />(Jl jty'F^�'n-l/veetvNvema�f <br />CITY "^ <br />Street mbar <br />ZIP Ccsm <br />STATE CA <br />CITY oc\ <br />STAT G IP <br />f <br />PHONEEXT. <br />APN # <br />LAND USE APPLICATION # <br />qEE j1#1 <br />I%UI) 5 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: <br />Stt� 7 8 2020 <br />�NVIRON N COUN7y <br />HEgrIV <br />THp� Tk . <br />ACCEPTED BY: V`fLA e S C-4 <br />EMPLOYEE M DATE: I Z <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Date Service Completed (if already completed): <br />- r <br />SERVICE CODE: 3 <br />PHONE# EXT' <br />Fee Amount: <br />Amount Paid <br />t <br />Payment Date 2 D <br />HOME or MAILING ADDRESS <br />Invoice # <br />Check # <br />FAX# <br />l ) <br />CITY "^ <br />ZIP Ccsm <br />STATE CA <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 FEDERAL WS. <br />--APPLICANT'S SIGNATURE: DATE: 1 1Z' Lb <br />PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTHORIZED AGENT❑ <br />I,fAPPLICA Is not the BILLING PARTY proof ofaullsorilation t0 sign is required Titre <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: �l..l L c r <br />COMMENTS: <br />Stt� 7 8 2020 <br />�NVIRON N COUN7y <br />HEgrIV <br />THp� Tk . <br />ACCEPTED BY: V`fLA e S C-4 <br />EMPLOYEE M DATE: I Z <br />ASSIGNED TO: �w` <br />EMPLOYEEM DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 3 <br />PIE: <br />Fee Amount: <br />Amount Paid <br />t <br />Payment Date 2 D <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025, I I I ( Otu--g3 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />