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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/OPERATOR —sl�) 1,�"I <br /> ��C "7✓? CHECK if BILLING ADDRESS E] <br /> FACILITY NAME / r/ <br /> SITE ADDRESS 3 37zip <br /> Street Number Direction Street Name Ci Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# I LAND USE APPLICATION# <br /> ATION CODE <br /> PHONE 92 EXT. BOS DISTRICT LOC <br /> C `1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME G PHONE# EXT. <br /> .��� .rersevs z-1 C1 3-�93Y <br /> HOME or MAILING ADDRESS FAX# <br /> CITY .' G �S �.7 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 or <br /> 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> —T <br /> PROPERTY I BUSINESS OWNER, -' OPEkATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �. b <br /> � W <br /> N O ?; <br /> FNS qQ�f " 9 <br /> 116N7- <br /> ACCEPTED <br /> NrACCEPTED BY: SS' �/� EMPLOYEE#: DATE: <br /> ASSIGNED TO: 7 , '''\ EMPLOYEE#: DATE: .2 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 7.2C <br /> Fee Amount: i 5 2— Amount Pai �sZ Uv Payment Date 71 /If <br /> Payment Type �,�p f Invoice# Check# Recelved By: <br /> 07/17/0D 48802-025 � v� SR ORMRod) <br /> Ott l <br /> +7 x (-7' of rtt-Mt-- <br />