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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH MPARTMENL' <br /> SERVICE REQUEST <br /> CE REQUEST <br /> Type of Business or Property / <br /> FACILITY ID# SERVI # <br /> OWNER/ OPERATOR 1 /�j/L CHECK It BILLING 80DRE55❑ <br /> FAcn.RvNAME <br /> SITE DRQ <br /> 5 nal Nu bar ircd n <br /> rcet me <br /> HOME or MAILING ADDRESS (It Different from Site Address) sn r <br /> Suss Number <br /> STATE ZIP <br /> CITY <br /> Exi. APN# LAND USE APPLICATION N <br /> PNONEIN <br /> ( ) BOS DIMICT LDCATION COPE <br /> Ex <br /> PNDNe02 <br /> CONTRACTOR / SERVICE REQUEST <br /> OR CHECK If BILDNG ADOREtfacl <br /> REQUESTOR Cr-r- Al. �Q gyp,i/0-5 EV <br /> p , 8 p <br /> BUSINESS NAME NM-- C <br /> 11omf or MAILING ADDRESS1112-4O �� n/r ��✓t✓- / D ( ) `� <br /> STATE ZIP O <br /> CITYp <br /> � nvr• At^ E GE NT: <br /> 1, the undersigned property or business owner, ope <br /> KNOWL rator er authorized agentof;actmoi <br /> acknowledge that all site and/or protect specific ENVIRONMGNTAL HBALTN DEPARTMENT houes rly ehaigassociated with this <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared fbis application and that the work m be performed will be done to accordance <br /> with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. DATE: <br /> APPLICANTS SIGNATURE' OTHERAX,THoRIz6D AGENT❑ <br /> OPRRATDR/1�IANAGER 13Titta <br /> PROPRRTY/BVRINES90WNE r00 o authorization In sign is required <br /> IJAPPLJ`CA is not the&1PAA P l f e owner or operator of the property located at the <br /> —ON TO RELEASE INTORMACLO ' When applicable, I,tb <br /> U O y eotechnicn) data and/or environmental/site assessment <br /> above site address, hereby authorize the release of as end all results, $ at soon as itis available and at the same time 'I 's <br /> information to the SAN JOAQUIN COUNTY ENvtRONMENTAL I'IEALTH DEPARTMENT <br /> provided to me or my representative. — o <br /> TYPE OF SERVICE REOUESTED: f eC✓ <br /> C40MMEWS: <br /> EMPLOYEE#: DATE: <br /> ACGEPTRO BY: <br /> ASSIGNED TO: <br /> EMPLOYEE#: PATE: <br /> Ply c <br /> Date Service Completed (it already compieted): SBiWIMCWE E{. <br /> Fee Amount: Amount Paid Payment Date <br /> Invoice# Cheek# Received By: <br /> Payment Type _ - -- --- -- <br /> Dela n ' SR FORM(Golden Rod) <br /> EHO 4g-02-025 Pos4SY Fax Note 7671 1-Z ' Q Pa9as <br /> REVISED 11/17/2OD3 To - From / <br /> Ca Joep a°. S G O E / <br /> panne M Phone R <br /> Fax N .)- - 3 Q j Fe.N . 4 7 <br /> i <br />