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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rniCid0 b--� <br /> OWNER/OPERATOR /� <br /> 1'Fi''1/t /iCG 1✓IQ �CFt In(1 /L I'/1 CHECK If BILLING ADDRESS <br /> FACILITY NAME llll//VVV 11 U.<4�7J l.11y 03t05 <br /> Nowoo <br /> SITE ADDRESS x,//�7t11(,/�J��g �,.{ t-ii2��1 <br /> r Street Number Direction �v""'�'dnstm NAma I Zi Coda <br /> HOME Or MAILING ADDRESS (If Different from She Address) C�LIDD reeG ae <br /> re <br /> ,Number PdttN <br /> CITYr 1 ao STATE 1 /C QW )-7 <br /> ZIP <br /> PHONE#I EAT. APN If LAND USE APPLICATION# <br /> (-IVA 259 8 . 550 I <br /> laoa ) yYVI Y/^I cO e BQ$DISTRICT LOCATION CODE <br /> (/'r' CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L5,;%o 3 <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME div PO3'9� 5G^ E" <br /> Ho EorM ING DDRSS FAX# <br /> PJ : UU061ON) 024161 r-?D <br /> CITY ID ��1��I"""� STATE 00 ZIP <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 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 Sod FEDERAL laws. <br /> APPLICANT'S SIGNATURE: //j�'/�1J I ' "j DATE: 3 I IOt�a 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING 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. PAYMENT <br /> �p 7 <br /> TYPE OF SERVICE REQUESTED: r l ) C o I I/y� n <br /> I U. by�' R E C <br /> COMMENTS: <br /> MAR 10 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Nell It EMPLOYEE#: DATE: Gl 2 <br /> ASSIGNED TO: L �c EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERACECODE: 1)U, PIE: <br /> Fee Amount: d/2 ,/ Amount Paid GS"2 Payment Date 1 `0 <br /> Payment Type Invoice# Cheeckk#c�/0 ��. 3?J Received By: <br /> EHD 48-02-025 ?k0 Wk- /b'7(fSR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 5C LK3 -0A14� <br />