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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> - CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Lcd 1 CSI 5 2 VD <br /> Street Number Dlrectlon Street Name Cit \ Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number J Slreet Name <br /> CITYtou 1rA STATE ZIP �J30 <br /> PHONE#1I >R. APN# LAND USE APPLICATION# —1 <br /> (2cR)- bz�p - 035 <br /> PHONE#2 EM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> r�w�01 \� CHECK if BILLING ADDRESS <br /> BUSINESS NAME l , 1' a P <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY STATE ZIP 0,55,Lk <br /> BILLING ACKNOWLEDGE NT: I, the undersigned property or business owner, operator or authorizedagent 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 /> APZ LICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJAPPLICANT is not the BILLING PARTP 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> APR 0 9 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): RACE CODE: /E: I O L <br /> Fee Amount: s SZ Amount Paid l S Z Payment Date fZ GG L <br /> Payment Type LS' Invoice# gW11# 1 Z 3 S' (�L g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />