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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME T <br /> _ SERVICE REQUES-f <br /> Type DfBusiness orProperty _ FACILITY IDN SFRVIC-RFQUFSI <br /> t Lc <br /> 04VNER/OPERATOR <br /> • ut_� �` \.�L ` C GN If BILLINfi AOORE55� <br /> I'MALiTY NAME �T <br /> Aa -T:' <br /> SITE DRESS <br /> t .I,Clo G L <br /> R ent NeneZI Cu <br /> HOME Or MAILING ADDRESS (If Different from Sitc Address) l _ <br /> f 3lreetN Fail e.e..r�i H I- <br /> Cfft h QST TE IF, <br /> I ONE#1 EzT. APN# LANo USE APPLICATION M <br /> PMQtiE P2 EXT, 803 DISTRICT <br /> LUCATIO"I CCGE II <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR - <br /> CrlECxIfB4UN!3AOCRFSSL.J i <br /> BUSINESS NAMEpeow ENT. <br /> HOME or MAILING ADDRESS FAx# <br /> l ) <br /> CITY STATE ZIP — <br /> BILLING ACKNOWLEDGEMENT: I, the unders;gned property or business owner, operator or au horized agent of same, <br /> acknowledge that all site and/or protect Specific ENVIRONMENTAL HEALTH DEPARTMENT t10UriV charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared th;s app ccatl and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes.Standards,SIA E a d kDEP.Ar I /- <br /> APPLICANT'S SIGNATURE:( DATE: �{ / <br /> PROPERTY BUSINESS OWNER❑ —'OPE OR I MANAGER OT AUTNORIZEo AGENT ❑ -7 1 <br /> IfAPPoc.4NT Is n01 the BIL, PARTY,Proof Of authOrU n to sign Is required Tir1 <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I. the owner or operator of the Property located at the above <br /> site address,hereby authorize the release of any and all results,geotechnical data and/or environmentallsi a assessment Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon a5 it IS avallable and at the Sarne time It is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED. <br /> COMMENTS: <br /> FQ <br /> alUN?4 <br /> ti 'CO M f <br /> ACCE?TED BY; C- <br /> f(A EMPLOYEE#: DATE: <br /> ASSIGNED T0: l�L� EMPLOYEE#: DATE: <br /> Date Service Completed If a.reacy eomple'l : SFJtVICFCoi C� PIE: <br /> Fee Qmounk I C1 Amount Pa ! /St JC.J Pg Date S— <br /> Payment Type Invoice# Ch # v <br /> 31� R eived By- <br /> Invoice <br /> 48-02-025 <br /> 07/17108 SR FORM(Golden Rod) <br />