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d <br />+, hem- i � C� � �•i .. <br />SAN OAQL_. .COUNTY ENVIRONMENTAL HEALSDEPARTMENT <br />SERVICE REQUEST <br />Type sriisiness a Prapert, <br />&::0-6T <br />��t✓�� r <br />FACILITY 0 # <br />SE�jRVICE REQUEST # <br />W COU14" <br />SAN NV RONME. ,A <br />TMF <br />oo <br />OWNE / OPERATOR <br />HEpLTH.DEPAR <br />APPROVED B <br />EMPLOYEE #://l <br />'9 <br />DATE: 2 <br />ASSIGNED TO: Aq 4e, i <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />_ <br />Q.o <br />_ <br />., <br />SITE ADDRESS <br />t I W <br />N' C, Y" m �' <br />h C� Yi �.� <br />C� � lqs—� 10 <br />Payment Date (2 0 <br />Sheet Number Direction <br />Street Name <br />city <br />Zip ode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />P �E� <br />Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE N2 <br />( 1 <br />Ex7. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RECIUESTOR ( CHECK if BILLING ADDRESS <br />BUSINESS NAM V1 PHONE# _ EXT' <br />HOME Or MAILING ADDRESS � �. ,,�� � FAX# <br />!I CITY STATE ZIP <br />\,10.;1e,�._ <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 or <br />activ;'y wili 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, Standa s, STATE and FEDERAL laws. <br />L <br />APPLICANT'S SIGNATITRE: _ �L. �_ 'DATE: <br />i1 e n wait MAN! Eft "6FF;i2 AI!T?!cazl I n A ,•FN -7- �T — <br />S^'= <br />If APPL/CLAN is not he BILLING PARTY. proof of authorization to sign is required Tine <br />AUTHORIZATION TO R. SE 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 datatand/or environmental/site assessment <br />informatioh to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />Drovided to me or my rearasentative. <br />TYPE OF SERVICE REQUESTED: Gjzz <br />&::0-6T <br />��t✓�� r <br />COMMENTS: <br />QEC 1. 4 <br />U <br />W COU14" <br />SAN NV RONME. ,A <br />TMF <br />HEpLTH.DEPAR <br />APPROVED B <br />EMPLOYEE #://l <br />'9 <br />DATE: 2 <br />ASSIGNED TO: Aq 4e, i <br />EMPLOYEE #: <br />6 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />ry <br />P 1 E: CA <br />Fee Amount: <br />,COIa-9. <br />Amount Paid <br />c� <br />Payment Date (2 0 <br />Payment Type ✓ <br />Invoice # <br />Check # 1-7 <br />Received By: <br />EHD 48-01-025 <br />SERVICE REQUEST F0 <br />