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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6-- SR0003945 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> t Arr'OVIJ <br /> FACILITY NAME 44 Box ✓ <br /> � '� <br /> SITE ADDRESS 7Q7 , . /I / v 5 •{�kTO � o7 <br /> Street Number Dlrectlon Ta <br /> Street Mme/ t L Cv H ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5,4 r4.C Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ezr• APN# LAND USE APPLICATION# <br /> 20 ) -5961 m <br /> PHONE#2 Exr. BOB DISTRICT LOCATION CODE <br /> (� ) 5 9 G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /^vn/' ^ <br /> ^ <br /> Q / / VY / v/^M— CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME VI" ' // PHONE# E"T <br /> HOME or MAILING ADDRESS FAX# <br /> CITY •� STATE ZIP i <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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,Stand=--- , <br /> RAL laws. <br /> APPLICANT'S SIGNATURFDATrrrE:T�� 7 <br /> PROPERTY/BUSINESS OWNERQ':.-- OPERATOR/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,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 time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: o E�V <br /> COMMENTS: <br /> !1JL � <br /> A o' r" 3 @ tJ.t -"o , cnm -SAN , 2 2021 <br /> ,/ PIVVIRQuI N COIJ <br /> Y'—Pgpc r p LA r1 S` y D P�NT <br /> At <br /> ACCEPTED BY: 1 hI EMPLOYEE#: DATE: <br /> ASSIGNED TO: �i. f EMPLOYEE#: DATE: <br /> Date Service Completed V(if already completed): SERVICE CODE: I- P IE: <br /> Fee Amount: Amount Paid n n t/ Payment Date - -(�2,[Ll <br /> Payment Type Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />