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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/OPERA OR <br /> f,�^L "��• — CHECKIf BILLING AOORESS <br /> FACILITY NAME <br /> SITE ADDRESS J -T I�N <br /> 2- C S SZ �jiw.�w �cl fYt <br /> Street Number Direction Street Name Ci[ Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> PA -1360183 Cwt <br /> PHONE#2 E^ BOS DISTRICT LOCATIQN CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> /- REOUESTOR 1 <br /> (._" <br /> <C/1 � //�'.�r�a CHECK if BILLING ADDRESS <br /> BUSINESS NAME � PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAX# <br /> `(\ CITY 'IN- <br /> STATE ZIP <br /> BILLING ACKNOW DGEMENT: 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, STATE and FERE laws. ,1 <br /> APPLICANT'S SIGNATURE: V DATE: O,qA (_ a <br /> PROPERTY/BusINEss OWNER❑ OP OR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IJAPPLICANT is e BiLLtNGPARi'Y 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: L S S J-S R N•IT <br /> P-1 CU <br /> COMMENTS: <br /> `/�d��1yl�✓ L✓/% � ��z� 14 q,Q.r1 c*�w�` S ��R 8 2014 <br /> V IENV IN co <br /> D,wr, HEgLIJNTV <br /> TH I)E/FlOARTiAll <br /> ENr <br /> ACCEPTED BY: ��(/�\� EMPLOYEE#: DATE: 2k t7 vy <br /> ASSIGNED TO: (�S a� a-U i b EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: SZS P 1 E: 2-&02- <br /> Amount Paid S��S(�(� Payment Date <br /> Fee Amount: 2—Ir / <br /> Payment Type Invoice# Check# �S�- ecel ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />