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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> Iz zS(Pall-YN JT- S 200 7 oUa3 <br /> OWNER/OPERATOR <br /> l CHECKKBILLING ADoREse❑ <br /> FACLRY NAME Cs�/ Lt�F�r t,E PI ^ <br /> SREAD�DRE - 1S7t1�tL'�6 <br /> N mb r <br /> H7or MAILING ADDRESS (If Different from Site Address) <br /> 4qAP, StreetNumber n <br /> CRY STATE ZIP <br /> PHONE#1EST APN# LAND USE APPLICATION# <br /> A )-10� - 0&f 2 --I `? O 4 � <br /> PWMEE#2 EM, BOS DISTRICT LOfATION CODE <br /> 1 e o S <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ('"')r„ ,L �lo� <br /> CHECK if BI WNG AODRE88 <br /> BUSINESS <br /> NAME { O 1O.1 cL A41-766, <br /> 1017 O e" <br /> NOMEor MAILING ADDRESS Full <br /> b-Q6 �VVH ✓ Y <br /> ( 1 <br /> CITY �IL4A `� STATE 4101- ZIP ci-- gO <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 DEPARTMIeNT hourly char.-CS associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certit'y 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 . and F DERAt WS. <br /> APPLICANT'S SIGNATURE: DATE: 79 r-0-f �" <br /> PROPERTY/BUSWESSOWNER❑ OPERATOR/ I AGER ❑ OTHER AUTHORIZED ACENT� /}i24c -rjeyT <br /> IjAPPL7Cnwr is not the B7LL7NG PARTY proof ofauthorization to sign is required 1 ��^'nrle <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 JOAQUTN 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 DP SERVICE REQUESTED: law., 64 C& PAL,- <br /> COMMENTS: <br /> UZ FCF��DT <br /> 0 F <br /> h' N" 46, F041 <br /> 14 <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7O/ lC- <br /> ASSIGNED TO: /V7 EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERNCE CODE: PIE: l60 <br /> Fee Amount: Amount Pal 37s.OD Payment Date 7 Q <br /> PaymentType Invoice# Check# Revived By: <br /> EHO 49-02-025 SR FORM(Golden Rod) <br />