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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> :<5/�F-1V A L V I/`J <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> GlSa o F - ✓t <br /> FACILITY NAME <br /> SITE ADDRESS 33 g8 /L� 12-0fID TE( gs 3 37 <br /> Street Number Direction Street Name CjtV Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S�QD ��l<,'r F/q ROA D <br /> /� <br /> ./ Street Numher Street Name <br /> CITY �714/v ��i GI� STATE ZIP SL3 7 <br /> PHONE#1 ,/ ExT. APN# LAND USE APPLICATION# <br /> (dog) 67Oo2- g)-90 05-0-0A <br /> PHONE#2 ExT. [66sDISTRICT S LocanQN CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS❑ <br /> G <br /> BUSINESS NAME <br /> ON F-5NF_ E <br /> PHONE# ExT. <br /> E 5 L oz - �s <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE Zip <br /> LOG <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 /> I also certify that 1 have prepared thi lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s, TATE and FEDE I,laws. <br /> APPLICANT'S SIGNATURE: 1 DATE: 8 LT 0 <br /> PROPERTY/BPSINF,SS OwNER�m OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If IlPPLICANT is not the BILL TVG 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. <br /> TYPE OF SERVICE REQUESTED:S0/1_ 5-"/ TAD/4-t N/ T2Arr-1-UAD/L 571101f5 <br /> COMMENTS: E�'E�V�►'p <br /> AUG 2 7 2020 <br /> SAN J0gENVQU1N COUNN <br /> HEALT IRONMENTq <br /> ACCEPTED BY: ����L. EMPLOYEE#: DATE: 17 �p �T <br /> ASSIGNED TO: 4(-7 EMPLOYEE#: DATE: A O'so <br /> Date Service Completed (if already Completed): SERVICE CODE: rPIE: )4 D� <br /> i <br /> Fee Amount: Amount Paid Payment Date �0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />