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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P,17- kE^/Ng I- IRE /D,5&1714 L <br /> OWNER/OPEtEF <br /> if BILLING ADDRESS❑ <br /> M1 ;,- 1 �/'lS• �,4n/n/E B GEFACILITY M 5 �7�42DSI S � oA-9 Loo <br /> Street Name Ci ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (Z05) 200 -3142 O/ - 170 -2 RA - 07 - 24 <br /> PHONE#2 ExT. <br /> [g;������TION CODE <br /> (2019) 3&9 - 94-00 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BU0- <br /> SINESS NAME PHONE# <br /> EXT, <br /> 03 <br /> DOME or MAILING ADDRESS FAx# <br /> .O o <br /> CITY ZIP 3�/ <br /> u 2 L o � STATE Cil- 9 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 4so certify that I have prepared this app ' ation and t he work to be performed will be done in accordance with all SAN JOAQUIN <br /> Co`1`TY Ordinance Codes,Standards, S 1qrE and FE - ws. <br /> APPLICANT'S SIGNATURE: DATE: 12 - 17- 0-7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THEIR 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 e SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me 7Wrepresentative.'41 / <br /> TYPE OFSERVI ESTED: /T9Q7-0 4aAP1A)1/ 0 Lu/T,q$/L Ir/ S7GlD DI-r6 E 1111/ <br /> COMMENTS: <br /> T 2007 <br /> -5) ENVIP,ONMENT HEALTH <br /> H <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: S3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:��2,— <br /> Fee Amount: Amount Paid �S Payment Date I <br /> Payment Type Invoice# Check 2 �y l Received By: N� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />