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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sm, �t ries S C-,) ��� <br /> OWNER/OPERATOR <br /> 1� CHECK If BILLING ADDRESS <br /> F <br /> C"� <br /> FACILITY NAME O CA S +J Q <br /> .J± S— <br /> �l n� c c, <br /> SITE ADDRESS r ( `l�ket J tJC f[J til I S 2 c Z <br /> 44- Street Number Direction Street Name C(C Zip Code <br /> HOME AI G ADDRESS (If affere t from Site Ad ress) <br /> r <br /> Street Number Street Name <br /> CITY STATE ^ ZIP2 <br /> cZ <br /> PHrNF#1 EXT. APN# LAND USE APPLICATION# <br /> l <br /> PHONE#2 r EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR +n n l <br /> ( , / l CHECK If BILLING ADDRESS <br /> BUSINESS NAME I PH NE EXT. <br /> — <br /> HOME or MAILING ADDRESS FAX# �7 <br /> CITY STATE / ZIP C721� <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 /> 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: '—LI� DATE: <br /> PROPERTY f BUSINESS OWNER OPERATOR/6ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Ti rie <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: S P <br /> COMMENTS: <br /> iec ;;v ® <br /> M4Y <br /> -SAJV joAQ 0? ?019 <br /> h ENV/ IJIN COU <br /> ACCEPTED BY: 0 EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:✓ U/n P/E:r� Z <br /> Fee Amount: �5 VV Amount Paid s 1== <br />