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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />i <br />C�� n /S�Q � CyEC/�RBILLINGADDRESS <br />FACILITY ID # <br />SERVICE <br />�REEQUEST# <br />SQ <br />OWNER/OPERATOR (-/1 N <br />l./U i1 <br />�ti'tN Yq v O <br />CHECK If BILLING ADDRESS <br />FACILITY NAME % �E'C { <br />54 / <br />CA,47t5 <br />i <br />SITE ADDRESS 6�.c� <br />Street Number <br />Direction <br />f�C �C-,4-('t= <br />Street Name <br />MANr <br />6- OGK%Cli\! <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Z <br />STATE ZIP <br />PHONE #1 Exr. <br />(445) ,6' _ 1IL30k <br />EMPLOYEE#: <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Ex . <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />EQUESTOR LO�V. P ci' N F (J m�AI,/ <br />i <br />C�� n /S�Q � CyEC/�RBILLINGADDRESS <br />BUSINESS NAME /'T ssir jl,-��ST- <br />COMMENTS: <br />NEI✓ <br />PH G �ZCOiG ExT• <br />HOME or MAILING ADDRS�SLW <br />J F/! �k..C.t4:r r �r <br />FAX# <br />1 1 <br />CITY <br />i <br />STATE ZIP <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 Coder, Standards, STATE as d FEDERAL laws,,---, <br />' p <br />APPLICANT'S SIGNATURE: DATES(:p� — <br />PROPERTY/BUS@IESs OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IJQ`��j�� <br />IffAPPLICANT is not the BILLflvGPAR proof of authorization to 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 environmentaVsite 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. P <br />TYPE OF SERVICE REQUESTED: T�O O (% ICA ri <br />C <br />RFciv / <br />COMMENTS: <br />NEI✓ <br />FEB 09 2021 <br />y E�RONJC <br />Chi COns4rucf ion �ll� @ {l'!Lu GO/� <br />INCOUp <br />t�gnvac�nhn9uyP�dds <br />�ma,J cvmTHDf <br />MANr <br />ACCEPTED BY: 11 1 <br />EMPLOYEE M <br />DATE: Z <br />"1 <br />Z <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 4323 <br />1 P1 E: <br />Fee Amount: # L'� (Q <br />Amount Pai <br />75-t b D <br />Payment Date 2 <br />Payment Typ <br />Invoice # <br />Check # J <br />Receiv d By: <br />EHD 45-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />