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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEREQUESTSREQUEST# <br /> S�0-t611"ZU <br /> OWNER/OPERATOR <br /> CHECK N BILIJND ADORESa0 <br /> FACILITY NAME /' U <br /> a G <br /> SITE ADDRESS /I� 9577 <br /> 3 52C'0 li . umber S �'L�(S /V /� E3C /�� <br /> HOMEor MAILING ADDRESS pr Differept from site Aad ) I n <br /> 7 S Se ooI #treatN IV e <br /> CITY U SATE ZIP <br /> L^ S3 <br /> PNDNE#'I APN# LAND USE APPLICATION# <br /> t6so) z2 _ 3Z� 2532-�-D(c <br /> PxaNE#2BOS OPa7 <br /> 0- LOCATION <br /> CONTRACTOR/SERVICE REQUESTOR J <br /> REQUESTOR <br /> e5S 'T)e a CHECK it BILLING ADDRESS <br /> BUSINESS NAME <br /> -a � U PHONE# <br /> 5 — Exr. <br /> HOME or MAILING ADDRESS FAX <br /> 73 5 S eeq,Zo CA 79 1 ( ) <br /> CITY n� STATE LP p� <br /> BILLING AC OWLEDGEMENT: I, the undersigned property or badness 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 that I have prepared this apphc - that the work to be perforated will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE and RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Z <br /> PROPERTY/BUSUYE4SOWNER0 OPERAT MANAGER ❑ Ortuat AUTmmuzED AGENT'❑ <br /> JjAPPLTCANT is not the Bff.UNG PAR7Y.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,f,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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: rr/� c <br /> �'TG�e�.J Z'N��CC�I Gti' _• vse !J-7< �I ( ��P�i<' GJ <br /> AccEPtED BY: < EMPLOYEE#: DAJ:0 <br /> ASSIGNED TO: EMPLOYEE#: ICU DATE: . <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: OIL <br /> Fee Amount: C7Z ,-U� Amount Paid �Jr _ Payment Date 3 'J <br /> Payment Type V 1'SA. Invoice# Check#W X-g 2L{I Rece' <br /> 'Itzelet'veb <br /> OCT 0 3 2ft <br /> SAN JOAQUIN COUNTy <br /> HEALTH DEpMAR IAL <br /> _. <br />