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r ' <br /> SAN JOAQUIN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID g nSERVICE REQUEST# <br /> Se 00s7z 1—+ <br /> OWNER I OPERATO , CHECK If E n uNa AODRESS13 <br /> FAcsm NAME /� T <br /> $READDRESS <br /> ' T I Rom 4m10 )y 9�J�de <br /> 4n Code <br /> HOME Or MA=G ADDREJlfIta Add ,% <br /> oSoviet Number <br /> CITY shoo-kiwSTATE LP 0 <br /> 30 <br /> PHONE#t a=. APN# LAND EAPPLICATION# <br /> ( ) 14 i <br /> PNONEC2 Ea. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK ItBILL <br /> BIla1NE89 NWE&A <br /> PHONE � <br /> y_ ' <br /> HOME or MAILING ADDRESSFA%# <br /> ( ) <br /> Cm y1 STATECk <br /> LP <br /> HII LWG 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE/"I Zb DATE:, <br /> PROPERTY I BUsOress OwNER[3( OPERATOR/MANAGER E30, R AtmmRMD AGENT� bi ee ?L912 <br /> If APPLICANT is not the BILLING P.atn7:proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property lom 44 at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite a 'B`sment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same 41,it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REOUESTEO: <br /> COMMEM: RECEIVED <br /> NOV 0 3 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMFNTA, <br /> -� <br /> ACCEPTED BY: EMPLOYEE#: IO�2itl �'' V n.� <br /> ASSIGNED To: EMPLOYEE#: to <br /> DATE: 1 L /,_ r <br /> Date Service ComplO (N already Completed): SERVICECODE: 04 PI (OD <br /> Fee Amount, Amount Paid l C y — Payment Date (( ?� <br /> Payment Type Invoice# Check#100 5 G D I IReceived By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />