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SAN JOAMIN COUNTY ENVMONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly •� FACII,LITY I`D# SEERVICE1RsEEZQUEST# <br /> Z- �l r�UV�3"115 gpnk'VII <br /> OWNER/OPERATOR <br /> .. CHECK N B Ruxc AoOReas❑ <br /> 1 FACILITY NAME <br /> SPEEAnDREss q�`f� <br /> so-a�Numlxr Dt wa stnatw V /P J>J.•c�oaa <br /> HOME Or MAILING ADDRESS fit Different from Site Address) <br /> atrutNumavr Savvt Namv <br /> CrrY STATE IIP <br /> PHONE#'1E"r• ANN# LA NDBREAPPLICAneNP. <br /> I <br /> PHow#L �*' 80.5 DISTRICT LOapIION CODE <br /> If ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> 4v _. CHECK It BcuxD AooRsss❑ <br /> BU91NE99 NAME PHONE# W. <br /> Home orMAILMRADDRO4S s� FAX# <br /> . •PCJ 'E�IO OC 1 ) <br /> CIN STATE /14 ZIP 9S7�, <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 flint I have prepared this a tion and that thew cit:to be perfotried will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stood, ATE FED L Is <br /> APPLICANT'S SIGNAT . -�`' -- D.ATE.- <br /> PROPSRTYIDUSLNESSOWNERP OPERATOR/MANAGER OTHER AUr1lORVSD AGENT 11 <br /> ! IfAPPIJCAAT(S not the BILLMrGPdRTT proofofaa(Garizdio)rrosiga$regrrlred T(de <br /> I AUTHORIZATION TO RELEASE INFORMATION: 14'hen applicable,1,the owner or operator ofthe property located at the <br /> P above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMFNT as soon as it is available and at die same time it is <br /> provided to me or my representative. <br /> In It <br /> ! TYPE OF SERVICE REQUESTED: {S LhPiUC�.2L_ Y c6'�✓ LN - / D <br /> I ComeEM . ¢t:a�,i, <br /> i <br /> FES Z 1 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONME 4TAL <br /> ACCEPTEDBY: ftIiWfq� L EMPLOYEE#: DATE; I / TMENT <br /> ASSIGNED TO: IMPl E PLOYEE#: DATE P. 2-1 ,-7 <br /> I ! <br /> t Date Service Completed already completed): SER�ACE CODE: Pl E: a <br /> Fee Amount: '� Amount Paidq ( 7 Payment Date %, , <br /> t 11-7 <br /> Payment Type v•. Invoice# p' Check# CrReceived By; <br /> EH040-02-025 ���......,.._.__.._,. <br /> I <br />