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I also certify that I have prepared this application and that he work o be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stand ATE and FEDER <br />APPLICANT'S SIGNATURE. <br />PROPERTY / BUSINESS OWNE <br />If APPLICANT is not the BILLING PARTY, pr <br />DATE: <br />OTHER AUTHORIZED AGENT 0 <br />uthorization to sign is required Title <br />SAN JOAQL . /COUNTY ENVIRONMENTAL HEAL1 EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />a <br />OvvygR / OPERATOR <br />- beg nO6JakC 1/ W • inclic_ CHECK if BILLING ADDRESS <br />FACILITY NAME v.) ona _The <br />SITE ADORES§.1 <br />/ -) 1 -7 la Street Number Direction <br />ec i / ic, "1 <br />----) (..A.A1 V1 Nai -I— S--17.1 t9E-6/7 9Zip Code 19 <br /> <br />HOME 0 AILING ADDRESS (If Different from Site Address) <br /> <br />s - 0 • If& X I "1 Street Number Street Name <br />CITY , <br />D•A eit <br />STATE <br />, CL7s110 <br />PHONE #1 Exr <br />( . ii07-70v APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOft-?)02 narititt i .corr_12,c2 CHECK if BILLING ADDRESS <br />BUSINESS NAME/K , _Tee cc \V___c_ pk EXT. PHONE # i //•\ 7_ 70 Li/V <br />WI) LI U <br />HOME or iNGADDRny I ,3i 1 <br />L..) <br />FAX # <br />( <br />CITY <br />t2—I\ fitY) <br />STATE cA. , ZIP S--31.610 <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 form. <br />AUTHORIZATION TO RELEASE INFORMATION: en 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. _ <br />TYPE OF SERVICE REQUESTED: F-0 k v 0.,c,,u \,5fe 6 hit-N.A..., RECEIVED <br />COMMENTS: <br />flEd 2 5 2020 <br />SAN JOAQUIN COUN <br />N TY <br />....EN : 0 11411:::: <br />HEALTH n —EPARNE NT <br />ACCEPTED BY: q y'v\ mo D EMPLOYEE #: DATE: <br />ASSIGNED TO: 0 0 OM IV <br />EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 0 PIE: l(p03 <br />Fee Amount: 4 \ D--)--2, N) Amount Paid 4 I, 1 -- Payment Date <br />Payment Type , „n r Invoice # Check # Received By: a(772( <br />00,64-:105•(ow5 SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003