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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Rrs-T� uRA/\JT <br /> I OWNER I OPERATOR /� rQ C <br /> /V`� 1 w�H CHECK if BILLING ADDRESS <br /> FACILITY NAME �v y Uv f 1 I, C U `� S *t Av r f1^�D 3A/v c!v 1Z I <br /> SITE ADDRESS 1� C l r 1 % 1 y� S 1 6� I J/J 9 5� 0 <br /> Street Number Direction \ Street Name C' ZiCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) N /� <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> Q01) �A°3- �% 3 i <br /> PHONE#2 E T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 me 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, and FEDERA s. <br /> APPLICANT'S SIGNATURE: r / DATE: yO — O ' Z U Z 0 <br /> PROPERTY/BtISI9VESS OWIYERK. O RATOR/MANAGE 13 OTHER AIJ'rnORIZED AGENT❑ N I - <br /> IjAPPLICANT is not the LUNG PARTY proof of authorization to sign is required Title <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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEI�N� <br /> FD <br /> APR 2 12020 <br /> SAN JOigQUIN <br /> ACCEPTED BY: C-1 �� EMPLOYEE#: <br /> ASSIGNED TO: \ - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d ` PIE:v-a u2 <br /> Fee Amount: \::_�-L.Uv Amount Paid a� — Payment Date . . 202 D <br /> Payment Type Invoice# Check# 2 Received By: <br /> UT <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />