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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 /> e Y"'l CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS I31� pr t'1 fes• �L'� (�`�ll [ 5���' <br /> Street Number Direction I ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 1�vcE1 c� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (A ) 3 053"7 5�- /�/o . �- ��� ., )3uc> 1,7sc <br /> PHONE#2 EXT. BOS DISTRICT L� LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � CHECK if BILLING ADDRESS <br /> BUSINESS NAME [1 PHONE# EXT. <br /> Cantu u�+� ac-fl v 7 <br /> HOME or MAILING ADDRESS FAx# <br /> `J�3 �5- 3 s (v21 ) <br /> CITYSTATE�^ <br /> GI. zip S 2v a <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,Standa , STA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ICI ( /� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M ER ❑ OTHER AUTHORIZED AGENT.[3.1 l'['✓u I—a Co,-1 6 Z L�Ir^ �r� <br /> If APPLICANT 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. I <br /> TYPE OF SERVICE REQUESTED: 5c7-1 ��l � ( �< / S U d Y re v,e <br /> COMMENTS: riI}yCn}e ICtG�C%�11�( s!!UL//y 5Ub1v11 C/l (J"Icl ✓ �3its, CEI`/ED <br /> J JuN 15 2020 <br /> SAN JOAQUIN C <br /> HEgLTH p NMENZAI TM <br /> ACCEPTED BY: G- 7G�-(/ EMPLOYEE#: DATE: �' <br /> ASSIGNED TO: A L— EMPLOYEE#: DATE: t-:11 <br /> ' 16 a 0,?J <br /> Date Service Completed (if already completed): SERVICE CODE: S ,) 3 PIE: d�vc� <br /> Fee Amount: �� Amount Paid Payment Date <br /> Payment Type Invoice# J= V L` I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />