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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty a of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 215+6At.f + r� IND <br /> 52103 Z�� <br /> O INN`,ER I OPERAT/�(��R <br /> 1 tn/� <br /> F1M� AM <br /> pJ�p\/� CHECK If BILLINGADDRES <br /> l..i1S IVeW <br /> SITE ADDRESS ^n reef Na�V'b <br /> u91P <br /> t mber Direction l�f treet a e CI 222i Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Qr(T�Q Street Number Street Name <br /> CITY STATE zip <br /> EXT. APN# LAND USE APPLICATION# <br /> Illow�� Z <br /> I I <br /> EXT. BOS DISTRICT LOCATION CODE <br /> '0'(( CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> G't n a. /�n J � n 1 CHECK If BILLING ADDRESS <br /> BUSINE$SN E '1 l�'�tt vl PHONE# EXT. <br /> mi CX1A s NQw ybatL I4 tJ ao1L4Lia-(-,eLe�� <br /> HOME or MAILING ADDR SS FAX# <br /> a30Dt t F�L ine f}�entt� ( lP�) 4✓�a-3�11� <br /> CITYS+ -�X F-tUUy) G STATE ZIP g5-ZQ <br /> BILLING 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 /> also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa -, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUJE.� _ DATE: <br /> PROPERTY/BUSINESS OWNER /. PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 i5 available and at the Same time It Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: fo .I l J V1 <br /> cimt- <br /> COMMENTS: <br /> m ictal ae fs P i zza e6IL e Co vna 7 co rn AUG 2 1 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � EMPLOYEE M DATE: <br /> ASSIGNED TO: h`I' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: ./Z PIE: <br /> Fee Amount: t.I1;\Q Amount Paid 7 Payment Date <br /> Payment Type Invoice# Check# D ps R ceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />