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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of mss orProperty FACILITY ID t SERVICE REQUEST <br /> �a "� �a -�'� ~r, ' 0020090 6 x` F95 <br /> OVOWR I OPERATOtR ctxcK if BU x AMXtEY' <br /> rd a r <br /> FnaInYN 0. e C-t.,C J " ( C o lG �^ra c G i <br /> WE ADDRESSS,Sl7 A v l f l e d d, �C. C `� C- <br /> 502d #k9cho Zr G <br /> HOME or Mmum; ADDwss (it Different from Site Address) 1 <br /> 's rCtt \ . rtwr I Slrtnt Iii tno _ D <br /> Crr,r — STATE zip R PA ENT <br /> PHW /1 Zero MN S LAND USE APPUCATOW / ED <br /> i 4 2021 <br /> Pi*mr n E^• SOS DISTMCT LO�Aiign CLUE <br /> JAN jOAQUN <br /> l ) COUNTY <br /> RONMENTAL <br /> CONTRACTOR I SERVICE REQUESTOR HEALTH DEpARTMENT <br /> REWESTOR C / CHECK if 11ILLIh ADD ❑ <br /> QVC t 4ez. ;3Ess <br /> /� � 1/ 1 r Pttaetr f Eur. <br /> BUSINESS NAME I C « c J f" 7`ry ✓ 91 y � 0 OdU3 <br /> HOME or MAum ADo�RESs FAx <br /> r <br /> Ti ! S C + <br /> CITY ► t� - oC STATE c- /fj ZIP 9 Lfx'o S <br /> BILLINGACKNOWLEDGEMENT; 1 , the undersigned property or business owner, operator Or authorized agent of Sams, <br /> acknawMedge that all site andJor Ixoject specific ENVp* +m-rr AL HEALTI1 DEPARTWNr hourly charges associated Wth this prolbd or <br /> activity will be billed to me or my business as identified on this form. <br /> I also Certify that I have prepared this applicati that the wom to be performed will be done in accordenoe with all SAN JOAOUIN <br /> COUNTY Ormnanoe Codes, SfarnfWdS, STATE and laws, <br /> APPLICANT' S SIGNA DATE: <br /> PROPERTY I SAIM E43 OWNEYin> <br /> OPERATOR I MANAGER ❑ OTHER AuRE <br /> rNORO A00fT ❑ <br /> !f APPLicAmTtha Rs i avr. PF4i]G proof of authorization to ston is requ"d <br /> AUTHORIZATION TO RELEASE INFORMATION; When appitcable, I. the owner cc operator of the property located at 1AC above <br /> site address, hereby authorize the release of any and all results, geotechni *i d3ts andfor environmr._nlai+site assessment iAEprmaRlton <br /> to the SAN JOAOUIN COUNTY EmvwjmmE.NTkL HEALTH D~Tl6CNT as soon as it is available and Ot the Sarre time it is provided to me or <br /> my represeMative, <br /> TYPE OF SERVICE REQUESTED: t / a <br /> cow+t+n� 0 rV/, /c1C� 41/ (y � F'��S �'1i J �. /e !Iy) f 1if CYL`m JT///fv� e -1 vii /A <br /> C 4l ) oet: t/ )`FS !DC i nldC� !/ f(3 4v4ilFs wi / z ve ( ! 7 " ' efltr y <br /> A+GcEPT1to BY; s Ei/pLonx #: DAIE / (l <br /> 4&P <br /> AsSIGh*D TO; (� r% EMPLOYEE �: DATE: ` 7 <br /> Date Service Completed (it alrradycompleted) : SWACECr70E: g , 2 PlE: & <br /> Fee Amount: kkl 070T. Amount Paid Payment Date <br /> Payment Type SG` Mvwce * Check ! � Received By: <br /> �t <br /> EHD 4tt-02-02b SR FORMjGotden RuO <br /> 07! 11108 <br />