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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :L iz 0J & 10&-+ <br /> OWNER/OPERATOR �r� " <br /> / W►LC4 pAct4r:�7Gp CHECK if BILLING ADDRESS <br /> FACILITY NAME r <br /> SITE ADDRESS <br /> Street Number Direction 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#1 ExT. APN# LAND USE APPLICATION# <br /> (2019 ) Gtaa -2-7gl 103-2,70-2Z PA - /9'000 75' <br /> PHONE#2 ExT. BOS DISTRICTLO11CATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME (L-.%., PHONE# Ems. <br /> La M v <br /> '1a ,G�al-F 66!3 <br /> HOME or MAILING ADDRESS FAx <br /> ?o a0x ��C, ( ) 3-,4 0 7---3 <br /> CITY 0Di STATE C, .- ZIP 15724 k <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 <br /> or 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: � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER IT 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 as it is available and at the sal me it is <br /> provided to me or my representative. '1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 07" S <br /> ,0�Q <br /> , , <br /> `Ty�F qR�T 4- <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E <br /> Fee Amount: 477 D unt Pai&ll3 oo Payment Date <br /> - a <br /> Payment Type Invoice# Check# INS-- <br /> S' Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />