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4 <br />NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />I ype of Business or Property <br />�� �1 CHECK if BILLING ADDRESS <br />FACILITY ID # SERVICE REQUEST # <br />PHONE# EXT• <br />d <br />HOME Or MAILING ADDRESS <br />Q c� -Z S `7 U ! �Ob `}7436OWNER/ <br />(CHECK <br />10PERATOR <br />if BILLING ADDRESS <br />FACILITY NA <br />e <br />SITE ADDRESS "1 '7 Z <br />Street Number Direction <br />HOME of MAILING ADDRESS (If Different from Site Address)C <br />Street Name city <br />Zi Code <br />� <br />• <br />CITY <br />Street Number Street Name <br />STATE ZIR <br />A <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Exr <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />O U2 <br />S 0 <br />(A)NTRACT(lR / ,CF.RVTf'T,' 1I2Tt1TTTPQ-rn-D <br />REQUESTOR <br />�� �1 CHECK if BILLING ADDRESS <br />BUSINESS NAME --- <br />s,U � <br />PHONE# EXT• <br />d <br />HOME Or MAILING ADDRESS <br />FAX # <br />&I its -C� <br />CITY _ 1� r )� STATE zip <br />nt,�Lrlvu �� nlvuwi mac; lyl fS 1-: 1, 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 or <br />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�rmed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards; STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ---am � � DATE: 2- <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ NUNAGER ❑. OTHER AUTHORIZED AGENT ❑ Q��,Q,R �� NT� I C �.; <br />ffAPPLICANT is not the BILLINGPAR7T proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASEINFORMATION: 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 />infon-nation 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: a� <br />COMMENTS: <br />1EE":& <br />ACCEPTED BY: N, 12-t� <br />ASSIGNED 70: <br />Date Service Completed (if already completed): <br />Fee Amount: 3c,® Amount Paid <br />Payment Type Invoice # <br />EHD 48-02-025 <br />REVISED 1 111 7/20 03 <br />ECIElVE® <br />AUG 222014 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPANTMENT <br />EMPLOYEE M <br />EMPLOYEE #: <br />SERVICECODE: C <br />3 q0, dD Payment Date <br />Check## � 621'5 - <br />DATE: 97 -2 <br />DATE: T <br />PIE: Z'3�' <br />Received` �By:,� <br />SIFQ 1�`l3i(n'F,od}` <br />