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e SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> MCNECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS -/ag- COet—DICee- <br /> lj}'j/.(J Gjs2(�s <br /> Street Number DIre0110n Street Name c1tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> GC - -A Street Number Street Name <br /> CTry STATE ZIP <br /> 0)ca 0 C (::::-, C\s -35 � <br /> 4)HONE#1 Exr. APN# LAND USE APPLICATION# <br /> (4101 ) 2 `L 12 --+5 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAME ^ SlIv IL/�S PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> Li C'Aq ( ) <br /> S <br /> CITY'S_ TATE ZIP <br /> 0 0 g 5 35 <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 F^ s. <br /> PLICANT'S SIGNATURE: DATE: 03 AL — Lk <br /> PROPERTY/BUSINESS OWNER❑ q PERAT AGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLlCANT is not the BILLING PARTY proof of authorization to sign is required Titte <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: � ' ,'t,��- P <br /> COMMENTS: , ,T As� <br /> MqR 1 g Fo <br /> 2021 <br /> N;/' C,qatNM�COUry <br /> ACCEPTED BY: V'. � ,A,v EMPLOYEE#: DATE: 7 a.� <br /> ASSIGNED TO: V ae AV/1V��/'l 'J EMPLOYEE#: DATE: JJ 'W <br /> Date Service Completed (if already Completed): SERVICE CODE: o� P/E: T <br /> Fee Amount: I�. O� Amount Pa dt-:,`/�'j Payment Date U <br /> Payment Type Check# Received By: 7771 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />