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SAN JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> REE DENTc L_ SQO93219 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> s kmvuo V N E <br /> FACILITY NAME <br /> SITE ADDRESS o2 Gly S Gf lziZAL I1 oL�-O(ill R b. 'FRA yT _'5 ,3 0 4 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) oZ 3 6d 7 11.4 N f EN RID <br /> Street Number Street Name <br /> CITY � n STATE ZIP <br /> frt CA qS <br /> PHO #1 ExT APN# LAND USE APPLICATION# <br /> ( *1 3810 - ql a(a2 -lqo -eo2 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> UON CH C 2N Q14 P E <br /> BUSINESS NAME PHONE# ExT. <br /> ES Co 5ULT oz - S <br /> HOME or MAILING ADDRESS FAX# <br /> x 371-4 <br /> ( a <br /> CITY n �n a4 STATE eA ZIP <br /> BILLING ACKNONVLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAi..HEALTH Dr..PARTMENT 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 this ap tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards E and FF AI..laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/IN,ANAGEll ❑ OTIIERAUTHORIZEDAGENT� <br /> If 1PPI,ICdrVT is not the BILLING R4x7'r proof of a thorization 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 availableft mte it is <br /> provides{to me or my representative. ftwo <br /> TYPE OF SERVICE REQUESTED: l`'SNL kFV P/ --owl WCIJ <br /> COMMENTS: FER 2 2021 <br /> SAN JOAQUIN CO <br /> ENVIRONMENTAL ON TY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C EMPLOYEE M ` DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date:Service Completed (if already completed): SERVICE CODE: Z '5 PIE: -Z6. C) <br /> Fee Amount: © InAmount Pa � �� Payment Date <br /> Payment Type voice# Check# 3Recei ed By:477F I <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />