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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII IfY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Pa U kL &etjs ! CHECK N BILLING ADDRESS O <br /> FACILITY NAM!IaC• <br /> SITE ADDRESS <br /> 'SmbarI�Ci�1ah <br /> HOME or MAILING ADDRESS (B Different f m Site Address) <br /> L <br /> ShvaNmber �15� re o5ldt Name <br /> Cm TA L <br /> PHONE#1 E.T. APN# <br /> .-. / LAND USE APPLICATION# <br /> l/j Q <br /> PHONE#I En. BOS DISTRICT LOCATON CODE <br /> ( ) U <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR'� / t, <br /> ant !`tn�FYa� WCHEcxlfBILUNGADDRES <br /> BUSINESS NAME C Exi <br /> Ho orMau. AyrESS CITYVOOM 14 V-2r— STATE . <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 <br /> or activity will be billed to we 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,S TE and FEDERAL laws. J } <br /> APPLICANT'S SIGNATURE: �j'fY � A— DATE: alz�1 ss <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT;(L.P^ L'J(„be,rA <br /> IjAPPLICANT is not the BILLING PARTY proojojauthorization to sign is required I ��rtee <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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail�ljq and at the same time it is <br /> provided to me or my representative. �'I ji <br /> TYPE OF SERVICE REQUESTED: EC-Yd '��SLe..� ,T <br /> COMMENTS: '� A <br /> ,/ V `` <br /> �LCtYZ�Q ®�' C'Sllj✓1 - SqN✓p os2016 <br /> FN�q CU/r,, <br /> C, <br /> y�lTyo lq`'�'� Y <br /> ACCEPTED BY: EMPLOYEE#: DATE; =/ <br /> ASSIGNED TO: Art I EMPLOYEE#: DATE; % /C <br /> Date Service Completed (if(if`(allrreaaddy completed): SERVICE CODE: P(L�E; O <br /> O L <br /> Fee Amount: ^00 <br /> o� Amount Paid �, ,Dd Payment Date (� <br /> Payment Type Invoice# Check# 8 <br /> 2./p`f-G� Received By: <br /> EHD 4ED 1111 SR FORM Golden Rod <br /> REVISED 11/17/2003 (� (�,G'� ( ) <br />