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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property ` FACILITY ID# ERVICE REQUEST# <br /> OWNER i OPERATOR <br /> �` �V �.,Q /r�� 1 y ��tl, CHECK If BILLING ADDRESS C� <br /> FACILITY NAME 2 1 rra 1�.1t lf�✓t 11 ` <br /> SITE ADDRESSI- <br /> SS6 Stmt Number cl� Zip Code <br /> HOMEor MAIDNGADDRESS (ff Different from Site Address) t1 `m S�yMO — <br /> Move <br /> _ StmtNumW <br /> Cm --11 ._— CKATE ZIP nye} <br /> LcJplt _1 <br /> I En. I APN Y LAND USE APPLICATION <br /> gy0g1 - <br /> Pmm#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR }�1,1G Mor icq t +_ *tr C) `I p' I ILLC CHECK N BILLING ADDRESS C� <br /> I>1v 'TL.1/CYI (�T�.� 1 Av��� Ea. <br /> BusiNEss NAME \IP t'1 �I EA '-` oOTroy� i p r lYT I o6 W. ya 90 <br /> HOME or Wn wG ADDRESS a FAX# <br /> l s, reef ( i <br /> Cm UM'1 STATE Zip Gi�•LF,O <br /> BILLING ACKNOWLEDGEMENT: 1• the undersigned property or business owner, operator or authoraed agent of same. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL?N DEPARTMENT hourly charges associated with this prcj"I <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 /> t <br /> APPLICANT'S SIGNATU�R(E/ � DATE: <br /> PROPERTYIBUs1NEss OwNERU OPERATOR/N AGER ❑ OTHERAtrrHOR1z.EDAGEN7❑ I �v rl�LcL <br /> If APPLICANT is nor the BILLING PAR1Y.proof of g rrhorization to sign is required T rir <br /> AUTHORIZATION TO RELEASE INFORMATION: Wben 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 asssessssmem <br /> information to the SAN JOAQUIN COUNTY ENVIRONmr.NFA <br /> TAL HLTit DEPARTMENT as soon as it is available and at th t Is <br /> provided to me or my representative. RECEIV <br /> TYPE OF SERVICE REWESTED: MAY 05 , <br /> \\- t� <br /> Couv itirse \ � Vomit TO clpefrijl— r® �• SIILJOAONINCOUNTY <br /> X171 i•t 1 1`� �`�� `� ENVIRONMENTAL <br /> REALTL DEMRTMEN f <br /> ACCEPrED BY: Vidal Pedraza EMPLOYEE 11: 6213 ])Are: 5-4-22 <br /> A95IGNED TO: Vidal Pedraza <br /> EMPLOYEE tt: 6213 DATE: 5-4-22 <br /> Date Service Completed orf already compbted): <br /> SERVICE CODE: 061 1 E: 02 <br /> Paid Amount PaPayment Date t> <br /> Fee Amount: 152 5 Z <br /> Received By: <br /> Payment Type <br /> 1(�,� Invoice JI kill <br /> a mt confirmation 143127827 Sl� �Z L SR FORM(Golden RUC) <br /> EHD -- cc <br /> REVISSEDED 1I111I/1Pyencon712003 � q <br /> �Q C J <br />