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'M--- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C� izcl3z <br /> OWNER I OPERATOR <br /> C /j ,r}A rA � � ^ o CHECK if BILLING ADDRESS <br /> FACILITY NAME I� co S pnAin D <br /> $READDRESS 2'[gLA CJ <br /> Stre let Nujjm�,ber I Direction t✓t Yr�Stra A Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2 tal NQ ; l l rk I �o <br /> L �I <br /> SlreeloONumber ,� Street Name <br /> CITY T9 (� STATE ZIP CIS3Z�) <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> /W1 I S 15 - 2�1 S I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR _ _ f I ,. <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEVr'l 'n �C o� PONE# EXT, <br /> J Y1 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 R l nGLrn L �e ( ) <br /> CIN &--\ STATE CA ZIP <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,Standards, STATE and F DERAL law . <br /> APPLICANT'S SIGNATURE: T Yl_�� DATE: -U -D <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization l0 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as IMS available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: IAN r-1 mec k YIW <br /> COMMENTS: <br /> AUG 0 6 2020 <br /> 8ANJQAQU <br /> iqpE/ <br /> AETHMLP <br /> ACCEPTED BY: �,� � EMPLOYEE#: DATE: _20 <br /> ASSIGNED TO: V- EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Cj Z PIE: 00 <br /> Fee Amount: * LIS � Amount Paid �6 D� Payment Date 94 52) <br /> Payment Type CQ2d� l Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />