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SAN JOAQUIN wOUNTY ENVIRONMEN_\L FAZALTh, ,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# REQUEST# <br /> [:�SERVICE <br /> C)0 { u -2 <br /> OWNER/OPERATOR <br /> A V I/•r F- � �O. �� � CHECK If BILLING ADDRESS <br /> FACILITY NAME K- 'l/"•J <br /> SITE ADDRESS J� ZV C,y .t?/`1�n7 kb S`-d �, P3 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t E T' APN# 1],C{` 080 — s l I 6D LAND USE APPLICATION# <br /> ( ) bz <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 11 ` '/� ( - \ <br /> SIL) S)/J�bL� �, N)ZVI(JGL� IT I-) <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ET' <br /> 5Uv-tE. ( o <br /> HOME Or MAILING ADDRESSFAI# <br /> ice. �. aoX q <br /> CITY S�Jr'L�� STATE CA <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of_dame, <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 ap lication and that the w k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and FEDERAL I S. <br /> APPLICANT'S SIGNATURE: DATE: II- q — c) <br /> PROPERTY/BUSINESS OWNER❑ O TOR/MANAGER OTHER AUTHORIzED AGENT 11 <br /> If APPL1CANTisnotthe B/LLINGPARTY proof of authorization to sign is required Time <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: <br /> COMMENTS: y�4 NO F4'4§'0 <br /> �� U�OTY <br /> AAT <br /> ACCEPTED BY: EMPLOYEE#: l DATE: <br /> ASSIGNED TO: EMPLOYEE#: [ DATE: <br /> Date Service Completed (if already completed): SERtncECoDE: P I E: <br /> Fee Amopnt: Amount Paid Payment Date '— <br /> payment Type Invoice# Check#ZP76- <br /> Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br />