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SAN JOAQUIN COUNTY ENYHtONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SFRVICE REQUEST# <br /> 590015Ca <br /> OWNER/OPERATOR <br /> CHECK if BILDNG ADDRESS <br /> FACILITY NAME L <br /> E A DR S <br /> T <br /> Street Nomber OIr2Etlon Street NameI(�C <br /> HOME or MAILING ADDRESS//(If Diffe ent from Site Address) <br /> 979 Street Number Street Name <br /> CITY ry STATEA 9S IP <br /> ah �PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> (S.30) &_926�i <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESMIL— <br /> REQUESTOR,74 eP >1 Vh <br /> CHECKif BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# EXT. <br /> C YEA N1 >3v) ,?o6 --'t t6V <br /> HOME or MAILING ADDRE81d FA%# <br /> 9)61 e 41� Z ( ) <br /> CITYyle,3'I C STATE ZIP r3-3 2 <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,laws. <br /> APPLICANT'S SIGNATURE:, -J�Iw e J l h 21� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT El <br /> IfAPPL/CANT is not the B/LLING PARTY 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 the or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> AwAPR <br /> , 04 2022 <br /> ACCEPTED BY: ra EMPLOYEE M DATE: <br /> ASsIGNEOTO: ( EMPLOYEE#: I DATE: l7/2z <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E: <br /> Fee Amount: Amount Paid �a Payment Date y y ZZ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />