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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cks � ­,SERVICE <br /> OWNER/OPERAT R <br /> Urlo f tae CHECK If BILLING ADDRESS <br /> SITEADDRESS /� / Gh )e �� C'�oC(/(�in <br /> Street Number Direction /"C`�' I Sir t NYme -J city 1g C <br /> odo <br /> HOME or MAILIND ADDRESS (If Different from Site Address) �QL il� /� Ve V/ /e, <br /> 31001 Street Number Street e <br /> CITY STATE ZIP <br /> �"0 C�OYi SRI I <br /> PHONE#1T API# <br /> �q) q^��� a5 <br /> �I LAND USE APPLICATION <br /> (aT1e <br /> NJ 13- f4o- 111 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR '/ <br /> John Chao a`-D /J V O CHECK It BILL!,-ADDI <br /> BUSINESS DAME e1 w n 0_O I�� 1 rte! )c (o lJ I CJ PHONE#V ti L TY V Q � -O I IOME Or fI�AILING E rew_ 'n 1 'Swan f FAX# <br /> OL ll V t--If- fix•- ( ) <br /> CITY /} STATE C 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 HFALTH 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,StanJTIA A <br /> APPLICANT'S SIGNATURE <br /> . DATE: l 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY.Proof of authorization to sign is required T111e <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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C Q!^ i /e A)f✓ �e <br /> COMMENTS: t ` l�G �j <br /> NOV 2019 <br /> SAN JOgQU! <br /> 0V RpN N COON <br /> ACCEPTED BY: EMPLOYEE#: / DATE: P NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: , ` IG. <br /> Date Service Completed (If already completed): SERVICE CODE: P1 <br /> E: I <br /> Fee Amount: ba (� Amount Paid j� Payment Date <br /> Payment Type <br /> invoiceill, Check 0 �q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />