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( v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST tbZ <br /> Type of Business or Prop," FACILITY ID# SERVIC EQUEST# <br /> H i4►v o5 trcm 1-lEf Qf ry Z z-t-fs � co<giq'e'7 <br /> / <br /> OWNER/OPERATOR y ,/ <br /> l-elI ' � /`yc'rl// CHECK If BILLING ADDRESS or <br /> FACILITY NAME AudS t/� <br /> SITE ADDRESS 3 S'7 /t r 5,/G c/q, � GI SSG <br /> Street Number cion N rae[Name Ct 7 Zip Code <br /> HOME MAI�LING 7A RVS (If Different from Site Add/red/jS) U�1��1�IV/ <br /> �� 1.0 P7 �1 rdl Street Number ` Street Name �C <br /> CITY ! C A /C `N STAT ,� ZIP Sys.2 d <br /> PHO E#'I O �` EKE APN# LANDUSE APPLICATION# / <br /> ;?-10) 2 8`2- zvaG <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> HOME Or MAILING ADDRESS cv- FAx# <br /> 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 i tified on this form. <br /> I also certify that I have prepared this appl' do and thaythe work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE 1d FE EknL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2/2J /2 c z G <br /> PROPERTY/BUSINESS ONNER❑ 06"4011/MANAGER OTHER AUTHORIZED AGENTO <br /> /f APPLICANT is not the BILLING PARTY pro 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 the sante time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: WY l rJ �C <br /> COMMENTS: <br /> 5 2020 <br /> HNV/RONf NN <br /> OUNTY <br /> LN DEPARrME/V r <br /> ACCEPTED BY: Y y 6 V .'1 EMPLOYEE M DATE: <br /> ASSIGNED TO: J 11 lJ J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:Iwo 2 <br /> Fee Amount: 2 . Amount Paid l� Payment Date <br /> Payment Type Invoice# CCheck# Received By: <br /> EHD 48-02-025 REVISED 11/1712003 " ' I0 JCC V`{ �q SR FORM(GDltlen Rod) <br />