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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY)D# SERVICE REQUEST <br /> iR�lf� SRoo � <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS 0 <br /> FACILITY NAM' <br /> L C ck-c Li <br /> SITE ADDRESS e-57 Lo.1n C _5-roc le TD 14 9 5 21 D <br /> -79L40 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> z 6 SS nCksoty U L Street Number Street Name <br /> CIN 937 ' STATE ZIP <br /> Tvrnc C 5 <br /> PHONE#1 EXT. APN# LANSDUSE APPLICATION <br /> (Ste ) 005PHONE#2 EXT• DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> TU - c + e (Sf6 9 91 Q n 5 <br /> HOME or MAILING ADDRESS FAX# <br /> NU wejTlavie ( ) <br /> CITY Ck w STATE / ZIP 95210 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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. p <br /> _-APPLICANT'S SIGNATURE: <br /> R�E 2-4D: � DATE: O /cJ/2o <br /> PROPERTY/BUSINESS OWNER LAS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR TP 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 envviif� a assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availaQlE'H pile time it Is <br /> provided to me or my representative. ��Ce G� <br /> TYPE OF SERVICE REQUESTED: COnSdIdth 1r, a y 2020 <br /> COMMENTS: <br /> SENVIRONMENTAL <br /> COUNTY <br /> PRMET QW� U4P H�,,LIHDENTFF-cx7 <br /> ACCEPTED BY: y� EMPLOYEE M DATE: <br /> ASSIGNED TO: V V l EMPLOYEE M �i+TYO DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O <br /> Fee Amoun a <br /> 2--U Amount Paid t S a Payment Date l <br /> Payment Type LS o1.. Invoice# Chet" 1 I -2,12 ZD Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003n-U91694 <br />