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SAN JOAQUIN rOUNTY ENVIRONMENTAL REALTY-DEPARTMENT <br /> tIr SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> AU . t:� eo33s <br /> OWNER/OPERATOR <br /> ^� CHECK If BILLING ADDRESS <br /> -('Rk'*IACASCOl IM <br /> FACILITY NAME <br /> $ITE ADDRESS <br /> C . L i3 <br /> I7 Z 0-b Street Number Olrection Street Name city Zip Code <br /> — <br /> HOME Or MAILING ADDRESS (If Different from Site Address) S <br /> 3 �a LGAAAf�) �• Street Number V' � � La. Name <br /> CITY �1 NATE Zip <br /> 75PW <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> (2 ) g83— I O'Z 116 —14 PA- OZ- 3 <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Mme, <br /> CHECK 11 BILLING ADDRESS <br /> EIST4E] <br /> BUSINESS NAME I PHONE# Ems' <br /> Zoq 1 334 -6523 <br /> HOME or MAILING ADDRESS (� FAX# <br /> OAK 9T. l )3 <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 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 aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENTV( CLI'✓ �j0✓' <br /> IfAPPLICANT is not the BILLING PARTY.proof of authorization to sign is required — ITirte <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 environmentallsite 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: S <br /> COMMENTS: PAYMENT <br /> /?�/ �xn li1oe10 r^v1 91 �pz RECEIVED <br /> *� 'JUL 0 2 '^9? <br /> �/ � n !:0 SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> /dodt 'do&, r ENVIRONMfNIK[HEY.TH OIVI° d, <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> EAount. <br /> Co plot (ifSERVICE CODE: —] PIE: <br /> ' 7 D Amount Paid - Payment Datee Invoice# Check# J 7 Received By: �✓ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-502 <br />