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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST / <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sf� 0031 `739 <br /> OWNER/OPERATOR <br /> LLY MVt u CHECK If BILLING ADDRESS <br /> FACILITY NAME _ - <br /> J�l CYIV � h <br /> SITE ADDRESS <br /> r,-/nZ- Street Number Direction Street Name CI 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t Ems• APN# LAND USE APPLICATION At <br /> (Z'0cp9�1 -Z�7 I J � � � ASO - 199 L] I� 00 -0c 2- 1 , <br /> PHONE#2 E>R• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORD&Oof CHECK If BILLING ADDRESS LA <br /> BUSINESS NAME PHONE# ExT' <br /> Ste c g 3 Zt�z <br /> HOME or MAILING ADDRE S FAX# / <br /> 40+5 CO/O/ir2CC Avi - (L ZZ- y <br /> - C <br /> CITY STAT ZIP (bZ <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: gel � �� DATE: /0/O -30-0Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER b 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 <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 ast i available and at the same time it is <br /> provided to me or my representative. {, 1 .� <br /> TYPE OF SERVICE REQUESTED: cfo t LDu A i h •JI`ry A I-" <br /> COMMENTS: �d ro� '�pp� k, ECEIVEC? <br /> 11 �,��i� �Ly�tc�lo;lf>`� 31 � � � <br /> �w�.' j `"' QCT` 0202 <br /> Zm <br /> rj v� �� UNT' 514 <br /> P BLIO HEALTH SERVICES <br /> • -} L r��,,,,,y�r ENNRONMEN3AL IF.4LTN uIVISi� <br /> APPROVED BY: �, EMPLOYEE#: DATE: �� -3 Q--, o-L <br /> ASSIGNED TO: , EMPLOYEE#: I b L DATE: (0 <br /> Date Service Com feted (if a eadycompleted): SERVICE CODE: 5ZS PIE: L�e`1• <br /> Fee Amount: Amount Paid `��, OU I Payment Date <br /> Payment Type _ Invoice# Check# T3 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6502 <br />