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SAN-JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Wit_, <br /> OWNER/OPERATOR <br /> ! —r L 1- Irl CHECK H BILUNG ACDRESS C� <br /> 'C <br /> FACI1_i7Y NAME <br /> SITE ADDRESS .5 O 1-_'76kf 7 <br /> Streit Number i II n tnpt amv cft ZID Cods <br /> HomE or MAILING ADDRESS (if Different from Site Address) `,'I b�� / P, N <br /> St'W Number Street Name <br /> CITYSTATE--r o <br /> rJP Z1P 1 �- <br /> PKNE#1("t.,9) ✓-�:^ -- �j,,,./ APN6�L_I !t�`�[�2� LAND USE APPLICATION# <br /> PHONE#Z ExT. <br /> ( ) BOS DISTRICT f....t' i LOrgnON CCOE <br /> I! — I <br /> CONTRACTOR ! SERVICE REQUESTOR 11 <br /> REQUESTOR <br /> 'A!j F3 I c- 1 CHECK if BILUNG ADDRESS O <br /> BUSINESS NAME LfTL Pte# Ec,. <br /> 32 <br /> HOME or MAILING ADDRESS FAxI <br /> L'ITY J J-Ot IG`-rL,I STATE zip 9521 <br /> 2. <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 DEPARIN1ENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 /> COUxTY Ordinance Codes,Standards,STATE and FFDFRAi. la s. <br /> APPLICA_NT'S SIGNATURE: DATE: <br /> PROPERTY/BI:'NESS OwNERX ( FIE TOR I,N ,"AGER ❑ OTHER AUTHOWlED AGENT❑ e <br /> /f,I PPLICAh'T 7S not Mir !i 1.Vr PAR proof of authadzadon to sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> infOtmatiOn 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. e y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 3� <br /> ENVIRONMENTAL <br /> HEqC ��'✓oq <br /> PERMIT/SEROCEgAp'; Do /ACCO <br /> i ACCEPTED BY: EMPLOYEE#: DATE:,674o- 1rh 7 +K RTMFN� <br /> ASSIGNED TO: ^ EMPLOYEE#: DATE: ( It __ K�„1�{ <br /> Date Service Complawl (if drvady compkded): I l SERvrCE CODE: - 7 FIE: 0 <br /> Fee Amount: 3 Amount Paid JLJ�,bo Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHDD2-025 <br /> REV SR FORM(Golden Red) <br /> REVISED',1/17!2003 <br />