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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />— <br />irs FACILITY ID # <br />000 2,-f 3 <br />SERVICE REQUEST # <br />EtQoo gyGLN <br />OWNER! OPERATOR <br />CHECK if <br />-D. atiL3)T 5.)^-)4)1 <br />BILLING ADDRESS <br />FACILIDAI(NAME <br />il --1/1/4/N 4 4A5 -o4) (5'5 <br />SITE ADDRESS <br />If ti k-6 Street Number <br />Al <br />Direction <br />pEelPrIN pvc- <br />Street Name <br />0 GO< je N <br />City <br />9 5.2 0 7 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />) t 2- fil Cil/t1 r, A C 5' r Street Number Street Name <br />City STATE ZIP <br />Cyr C.7-- <br />PHONE #1 EXT. <br />(E(08) 00 () <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(2 ,c ) '177 --g 0 `7 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUES_WR <br />Pi\ L:5 n. -‘1A411 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />11 L(t15- A/ k.:(1Pli A) A v (- 3 'A CgTav Ct+TIA) <br />PHONE # <br />(.2k, ) (i)) -61 1 <br />EXT. <br />Home or MAILING ADDRESS <br />1 4 ..)-- P1 EM-rip-( ;7— <br />FAX /f <br />( ) <br />CITY P1/1 N7-6-. C7)— <br />STAT„,, ZIP 3133? <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 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TE -rid F ?ERAL laws. <br />PPLICANT'S SIGNATURE: DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 <br /> <br />OTHER AUTHORIZED AGENT 0 <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: RECEIVED <br />COMMENTS: <br />1 etin CA(ife,C <br />t-Q-A-efX1-6kk-- <br />, <br />j9.-- A v-t ko-&- <br />K - <br />DEC 0 1 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: kArX S EMPLOYEE #: q CI .30 DATE: <br />ASSIGNED TO: VI' dal 7' EMPLOYEE #: (.12)4 3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 5;.....--3 13 /E: Vol <br />Fee Amountik LI slo .du Amount Paid 4 (cc, ___ Payment Date i 2.- 1 7 - <br />Received By: n8_7 Payment Type Invoice # Check # 1 1 0 3---_,z_ <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)