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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if <br />alAr\-- \t' ("" s Iv- <br />BILLING ADDRESS <br />FACILITY NAME <br />C3v,.4\ te5 ecd-s k Dc . i' 5 <br />SITE ADDRESS <br />/75 Li Street Number Direction <br />/\-Ao. ‘, ,•-% 5 4 <br />Street Name <br />Esc.' l.. ,..-, <br />City <br />9S320 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />(3 ...CIA..tsk ri s k- Street Number <br />--/-cl r, ,'_ icc ,,t5 5 -/-- <br />Street Name <br />CITY STATE ZIP <br />en A .-1 CPT `75".?2 a <br />PHONE #1 Err. <br />9 G <br />APN # <br />227 -15/ - 0 /3- <br />LAND USE APPLICATION # <br />PHONE #2 ea. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />-441$100, ;14)•sr\ \_.( T,..c. • <br />CHECK if BILLING ADORES/ <br />BUSINESS NAME PHONE # EXT. <br />HOME or MAIUNG ADDRESS <br />s)r- <br />FAX # <br />( ) <br />CITY t-- c- 1 C <br />STATE <br />( rt <br />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 Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> ad, <br />DATE: //—'-2/ <br />PROPERTY / BUSINESS OWNERD OPERATOR / MANAGER gt OTHER AUTHORIZED AGENT 0 <br />IJAPPLICANT 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 availabPAitilrnhe same time it is <br />provided to me or my representative. Ari <br />TYPE OF SERVICE REQUESTED: 'pla n atu,K NO V <br />COMMENTS: <br />0 9 2021 sAN JoAQ,,, <br />HEZiviRoV couivry LTH „,,, evrAL <br />'ct'ARTmENT <br />ACCEPTED BY: t int terli EMPLOYEE #: <br />iqq0 <br />DATE: I 1 /q 17,1 <br />ASSIGNED TO: <br />LA (1/(/ <br />EMPLOYEE #: 50 W DATE: 1 I Iq 1.4 1 <br />Date Service Completed (if already complete ): SERVICE CODE: PIE: / PIE: 0) <br />Fee Amount: o iv; Licli 'd d r Amount Pa 4570. 6-0 Payment Date 1;7z/ <br />Payment Type ._321.__)-- Invoice # Check # 1 31/(6-077 ( ecei d Byy- <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003