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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPANT 2024 <br /> SERVICE REQUEST ?g8.1vt <br /> Type of Business or Property FACILITY ID # SERVICE REQUE8YTVr <br /> Re-O. i I � P00 ek) �=7 / GV, 00- ? '1 <br /> OWNER J OPERATOR <br /> CHECK ifBILLING ADDRES3 ❑ <br /> FACILITY NAME <br /> $READDRESSlJ /7��a /I/ Ibc���. i1 �jjlo v1 414Ay.Soi OJT <br /> SIN u ber D o St e e C Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) Par dr? e <br /> J �{ Street Number Street Name <br /> (% <br /> CITY cs / J STATE "4 ZIP <br /> PHONE #1 �• APN # LAND USE APPLICATION # <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C <br /> CHECK if SILLINO ADDRESS <br /> BUSINESS NAME � PHONE # EXT•yC6y WOMEN <br /> 9 �i � � as3 <br /> HOME or MAILING ADDRESS 60 rlvrlel�Le� JOE)D FAX # <br /> CITYV STATE A zip cl dV9 00L <br /> r` tel. <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 /> 1 also certify that 1. 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 nd FED14P <br /> 4AL laws . / <br /> APPLICANT'S SIGNATURE : LDATE: �JA ! 4 Z) <br /> PROPERTY / BUSINESS OWNERD OPERATOR / MANAGER 13 OTHERAUTH0RIZEDACENTY7 Y '+*, T•Tccf <br /> Zmar <br /> IfAPPLICANT 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 same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: u S T Z RECEIVED <br /> COMMENTS: OorhV.L &/}.-/ f C� -1 � /�-�G OCI 9 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: t • 7 r�� � EMPLOYEE DATE: �� <br /> SCJ <br /> ASSIGNED TO: � �• �� EMPLOYEE #: DATE: 77 <br /> 1� <br /> Date Service Complete already completed) : SERVICE CODE: l PIE: L 9 <br /> Fee Amount: Nr y — rz� Amount Paid !� 5 ` . tpd Payment Date r Z J <br /> Payment TypeC r• j 't Invoice # Check ( 117 y 3 0 1 il 9 1 Received By: t� <br /> EHD 48-02-025 SR FORM (Golden Rad) <br /> REVISED 11/17/2003 <br />