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NAN J OAQUIN COUNTY ENVIRONMENTAL-HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type ofBusiness or Property • FACILITY 1D# SERVICE REQUEST# <br /> OWhiER OPERATOR <br /> J 1 J ) r r I 1LLING ADDRESS <br /> FACILITY PiAftlEYYY L� Lek/ <br /> �)AJF, <br /> SITE ADDRESS 4NO <br /> '40(0-51SUM Number Direction Street Name 0tv de <br /> HOME or MAILING ADDRESS (If Different from Site Address)) <br /> r <br /> G ,c) y 1 2- Street Number Street Name <br /> CITY STATE ZIP <br /> 939-53 <br /> � e�N � .S3 <br /> PHONe#1 EXT JAPN# LAND USE APPLICA ON# <br /> PHONE#2 EXT. BOS DISTPJCT LocAn on CORE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUr'STOR <br /> REQUESTOR rrt��• � (( <br /> ^ �6 c CHECX if BILLING ADDRtES <br /> BUSINESS NAME w ` N - PHONE# [� T <br /> dg{LJl e� L S"{12�C-fit 2--^ ZU� <br /> HOME or MAILING ADDRESS FAx# 248 <br /> Cho 0 -70 ( r 4f 2- , <br /> Crry STATE / ZIP C1- 7 O - <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 ENvjRoNMENTA..HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this fonw-M <br /> I also certify that I have prepared this application and tbat the work to be performed will be done in accordance with all SAN JOAQUfN <br /> COUNTY Ordinance Codes,Standards, STATE and EDErcA ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ 6th <br /> OPERA O i AGER ❑. OTHER AW-HORimm AGENT _ <br /> IfAPPLdCANT is no '6a <br /> .i TY proof of authorization to sign is regUirea 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 COuN'rY ENvtRoNMENTAL HEALTH DEPARTMENT as soca as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> ", L ` <br /> COMMENTS: �� �A /G� F EFCEIVED <br /> 117f6 U6?,,;Z W <br /> �t�Ji�?•"1JGOUrtn <br /> SAN JC)RONM AMM 13T <br /> ACCT-PTED BY: MPLOYES#: DAA: , <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: CyZ-Z� PIE: eqtzo( <br /> Fee Amount: , o d Amount Paid ��, Payment Date `Z <br /> Payment Type t f Invoice# Check# W73 Received By: <br /> EHD 4&02-025 <br /> REVISED 1'Id17MO3 <br />