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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �ec')6 0 lz--07- <br /> OWNER/OPE T IR <br /> C W8 CHECK if BILLING ADDRES� <br /> FA IUTY NAME j <br /> /' <br /> SITE ADDRESS <br /> lu 12- Street Number I Direction V� � Str@ .� k city �Zip Code <br /> HOME or MAILING ADDRESS (f Different from Site Address) 1(— <br /> ( Street Number Street Name <br /> CITY STATE ZIP <br /> u G1 tCA CA,52kAz <br /> PHONE#1 _ EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( IL-3 OZ- 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR, <br /> 0 e , CHECK If BILLING ADDRESS <br /> .19\\ 1A r-JCC; \C--�kA <br /> BUSINESS NAME PHO E# EXT. <br /> n ' 02LSS-8-73R <br /> HOME Or MAILING ADDRE S FAX# <br /> i_-c L CIS 2 Z ( I <br /> CITY STATE ZIP <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,Standard ST TE and FED44 laws. <br /> �/ 2 / <br /> APPLICANT'S SIGNATURE: �` DATE: C)3j <br /> PROPERTY/BUSINESS OWNERYJ OPERATOR/MANAGER ❑ 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, 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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t?.4 time it is <br /> provided to me or my representative. R � <br /> TYPE OF SERVICE REQUESTED: \(1 <br /> COMMENTS: ly -2020 <br /> /H A /,U/N�THO�Mj,C0 <br /> UAl 7Y <br /> NT <br /> ACCEPTED BY: �� \(`I �� 11"1 EMPLOYEE#: DATE: Z�\ <br /> ASSIGNED TO: c� , �ir�\'� EMPLOYEE#: DATE: -3\�\ <br /> Date Service Completed (if already completed): SERVICE CODE: O P/E:'` 1� <br /> Fee Amount: <br /> h4���i L Amount P ' Uv Payment Date <br /> Payment Type �� Invoice# Check# eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P�G��B3SlP <br />