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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DONVTS SHOP 2 645 5 (260 5r) 3F <br /> WNER/OPERATOR <br /> I—I \`" CHECK If BILLING ADDRESS <br /> F�1' <br /> ACILITY NAME VD r DON 1' T(' <br /> ITE ADDRESS /nr� /1y (//V ` J 510i:✓1< OV-1 9521 v <br /> Street Nomber DlreCtion Street Name Cit Zip Cod. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> / CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME DIF 1, ON f V 1 r S PLNE#) 2 _4 -13 <br /> E><r <br /> oll <br /> HOME Or MAILING ADDRESS FAX# <br /> V A ky ay e 0 ( I <br /> i CITY s ` 1 0 V1 STATE ZIP 915 'Z to <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: ,q�t( DATE: IIA �/ ) $ l Y, 7- <br /> PROPERTY/BusiNEss <br /> PROPERTY/BUSINESS OWNER R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION.When applicable, 1, 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 antNppt(•,,time it is <br /> provided to me or my representative. �YJ��7' <br /> TYPE OF SERVICE REQUESTED: �� (,{,(f�SJ y- <br /> COMMENTS: jiblt 2022 <br /> SAN JOAQUIN COUNTY <br /> NVRONNTAL <br /> HEALTNEIDEPMEARTMENT <br /> ACCEPTED BY: �f� L EMPLOYEE#: DATE: _ <br /> ASSIGNEDTO: EMPLOYEE#: DATEF-1/• IS - 2.2- <br /> C CA <br /> Date Service Completed (if already completed): SERVICE CODE: ('�(P PIE: /&0 -1 <br /> Fee Amount: t y 00Amount Pal ISlO,DD Payment Date 7 !g Z <br /> Payment Type I Invoice# Check# - SL (Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 'x"74032 <br />