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APPLICANT'S SIGNATUR <br />PROPERTY / BUSINESS OWNER <br />SAN JOAQUIN _ ,UNTY ENVIRONMENTAL HEALTH L._ ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />— Iv \ FF- <br />FACILITY ID # AERVICE REQUEST # <br />k 5.00X1(//tt <br />OWNER! OPERATOR , <br />.,' CHECK if <br />,evic.,y c/c --7-7c-i-7,-----z_. BILLING ADDRESS <br />FACILITY NAME <br />/(5L-/7cr-- c 7/64-/ 3-C>P19 74C <br />SITE ADDRESS 4 6.e; 0 0 <br />Street Number I Direction <br />c d 7 /76- / /1 tiC / (:/0,- <br />Street Name 0 c7 ' City <br />g5-270 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />1,c- /I 71-7"-L-:---/ 72/6,j _///C-l.' /,CT,, Street Number Street Name <br />1 CITY i , STATE ZIP , <br />PHONE #1 Ext. <br />( c' Cd • 2?-195(e9 <br />APN # LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Ext. <br />HOME or MAILING ADDRESS FAX # <br />( ) <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, Standar s, STATE and FEDERAL laws. <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 envi onmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabl <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: V7itl (II. c-2, <br />—U:C1 V <br />COmmENTS: At 1 / 2020 <br />OU17 <br />SA JOAQ <br />ENviRoNMENTAL HEALTH DEpARTA4ENT <br />I ACCEPTED BY: , <br />V: (41-19L 4 <br />EMPLOYEE #: DATE: if <br />ASSIGNED TO: <br />{ 7A <br />EMPLOYEE #: DATE: I / 7 4/4 ) <br />Date Service Completed (if already completed): FSERVICE CODE: NI PIE: <br />Fee Amount: ' ),,)-'t.v Amount Paid s( ---c:? ; - Payment Date <br />1 11/(/26(_-6377 <br />Payment Type I, aoh Invoice # Check # Received By: fi <br />OPERATOR / MANAGER • OTHER AUTHORIZED AGENT El <br />DATE 7— - <br />Title <br />y time it is <br />END 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)