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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#� SERVICE REQUEST <br /> GAT ,(Tfl-19N Z <br /> OWNER/OPERATOR <br /> NCHECK if BILLINgADDRESSIM <br /> FACILITY NAME co �) >h w r7 <br /> SI D (l//���Jyr7� `l I� 2 <br /> 5lipet Nurnbar Direction S!� Name 0J CI �ZI "Code <br /> HONE or AILING ADDRESS (if Different from Slte Address <br /> Street Number fteel Name <br /> CITY STATE ZIP <br /> NONE t E-, APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE42 Err, BOS DISTRICT LOCATION CODE; <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr' <br /> HOME or MAJUNG ADDRESS FAx# <br /> CITY STATE zip <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 th' rm. <br /> I also certify that I have prepared this application and that the ork t beperformed will be done in accordance with all SAN JOAQUEN <br /> COUNTY Ordinance Codes,Standards,ST an7SDE la a U <br /> APPLICANT'S SIGNATURE: DATE: I <br /> PROPERTY I BUswE5s OWNER L OPE R AGER ❑ OTUER AUT170RIZED AGEtiT❑ �1 ` <br /> IfAPPLICAw is not the BILLING PARTY.Proof of authOrilation to 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 ENVrRoNMFNTAL HEALTH DEPARTMENT as soon as it is available and attlyc,same time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: Consultation JAIZ7C <br /> �� ]' <br /> COMMENTS: 1)4'02 <br /> Sq NJpq <br /> HFq� HbE qRN��NTY <br /> rMFNr <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 12-24.20 <br /> LASSIGNEED)TO: Stephanie Ramirez EMPLOYEE#: 1084 DATE: 12.24.20 <br /> te Service Completed (if already completed); SERVICE CODE: Obi P i E; 1602 <br /> Fee Amount: 152 Amount Paid Payment Date Z� <br /> Payment Type ' Invoice# Check# 1 3T 7 Recely d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11197i2001 <br /> �-o�u�gz3 <br />