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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 91 Cl Z <br /> OWNER/OPERATOR <br /> _ AC,, <br /> \� CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME dQ+2— _ <br /> SITE ADDRESS I /l� P02-a- <br /> -P-4L E cCC.l, O(� L7 -3� <br /> Street Number Direction Street Name C" Zi Code <br /> HOME Or MAILING ADDRESS (ff Different from Site Address) I " !-1 O OJou K-v'�_ <br /> Street Numer bStreet Name <br /> CITY VkA e <br /> O S STATE 6A,- ZIPJ <br /> PHONE#1 ExT7 APN# LAND USE APPLICATION# <br /> 33 - q <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME \ PHONE# ExT- <br /> HOME orMAILING ADDRESS FAX# <br /> I-?,Ll . l ) <br /> CITY "oct�t� <br /> STATE CA ZIP 0/ <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,S ATE nd FEDE laws. <br /> APPLICANT'S SIGNATURE: 4 DATE: , <br /> PROPERTY/BUSINESS OWNEI�q(J 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, 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Lc-. ",L`lv <br /> COMMENTS: pn <br /> MAY I � 2020 <br /> SA Al Jp <br /> FNV/RQIIIN COU <br /> NSALTy p P�MENS <br /> ACCEPTED BY: C.L lam! S `, EMPLOYEE#: DATE: ! <br /> ASSIGNED TO: �` EMPLOYEE#: DATE: _2 <br /> Date Service Completed (ff already completed): SERVICE CODE: ®�Q P/E: o� <br /> Fee Amount: 2 Amount Paid l 5a Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> FHT)4R-m-n9..ri SR FORM 1rnit1an Roil <br />