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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0D asg0v pg;253t� <br /> OWNER/OPERATOR ����� �/ �;�� <br /> t'� CHECK If BILLING ADDRESS <br /> FACILITY NAME L77f->'5 <br /> L( 41 D <br /> S/ITTEADDRESS `l r� 9 <br /> / 3 Street Number Direction "AC�Sireet Na �O S1 G� 01 Z�Ze <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Ed Street Number Street Name <br /> CITY STATE ZIP cD <br /> STocel CA/ C.d `SLD <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (?,oq) zto _ 7-76b <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � <br /> CHECK if B?ILL�ING/ADDRESS <br /> AC&O <br /> GO AJ � _7D- Q <br /> BUSINESS NAME PHONE# EXT. <br /> GuaA t 2/O <br /> T f9 <br /> HOME or MAILING ADDRESS / FAxIt <br /> dc2 7h2 god La ( 1 <br /> CITY (�C l- O,4J STATE</1 ZIP �FSLO <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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: '` DATE: 09- Fry/ - ZA L O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization f0 sign is required Title <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. PAYEDIT <br /> TYPE OF SERVICE REQUESTED: VICEIVE® <br /> COMMENTS: C.VVYnV1 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> MEJ,LTH DEPARTMENT <br /> ACCEPTED BY: fl n!1 A/1 O EMPLOYEE#: DATE: 9-129-2-0 <br /> ASSIGNED TO: S , SytAy — EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: nw <br /> Fee Amount:* Amount Paid 1 S7 2- - Payment Date / <br /> Payment Type V1, Invoice# Chdc # 1115 l Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />