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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#-. - _, SERVICE REQUEST# <br /> OWNER l OPEIR <br /> � V-c �i Lc r lJ G�► W . <br /> � CHECK if BILLING ADDRESS <br /> FAc[LITY NAME <br /> L Ona Cakv-fcq PvLa1 rb A <br /> SITE ADDRESS 43Q_ ' V t 'd <br /> Street Number Direotlon 1 Street Name Ci Zi Gode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 f�I ♦��, M �,i <br /> Street Number \V eet Name ,r�( <br /> CITY STATE ZIP <br /> 8531 I <br /> PHONE#T Exr• APN# LAND USE APPL1cAnoN All <br /> � 5 -ZZI-Z71p ',2 o5 <br /> k c2�U Q75-l.p. Err. SOS D��� 1..oCATION�C�oDr; <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> eww CHECK if BILLITIG ADDRESS <br /> BusiNI=sS NAME _7_ "AR <br /> NE$' EXT. <br /> T � Iiin ZZI-ZIT <br /> HOME or MAILING ADDR SS FAX# <br />�. CITY t?Ia STATE CA Z[Pq 53-7 <br /> BILLING ACKNO EDGEMENT: 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 /> 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 FaDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1 I o—.l -7 <br /> PROPERTY/BUSINESS OWNER OPERATOR l MANAGER © OTHERAurHOR1zED AGENT <br /> 1f APPL r,4NT is not the SrLLlNG PARTY.proof of authorization to sign is required vile <br /> AUTHORIZAtON TO RELEASE INFORMATION: When applicable, 1, 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 environmentallsite 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 t.o me or <br /> my representative. -- <br /> TYPE OF SERVICE REQUESTED: 'F-1�0r& � ±2'o <br /> COMMENTS: 1 ••�99� <br /> . H sE COU <br /> X417 <br /> I <br /> AID) , <br /> ACCEPTED BY: � EMPLOYEE#: DATE: I _ _ f 1 1 LO 1 -7 <br /> ASSIGNED To: nfY EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 10 <br /> PIE: <br /> Fee Amount: Amount Paid)3q ) Payment Date � ��/17 <br /> Payment TypeInvoice# Ct Check# .3�T�7 Received By: <br /> j <br /> 071 D 4 8Q2-025 SR-FORM(i olden Rod) <br />