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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 1laFACILITY ID SERVICE REQUEST tl ' <br /> Pl a6co — Tj00�3241 Ga0C)M <br /> OMERI OPERATOR ral _e` ��/.P/�/P HSC CXELnOBILVNGAWIyos <br /> FAcarr,NAME C�/ea e :Y/nP ' <br /> Sm ADDRESS327/ V Ls W M� U ' <br /> saesrn�e.r ox.�m. <br /> HOMFor MnUIIOADDRESS (If Different from Site Address) <br /> saeel ae. se:: .. - <br /> CIrY STATE ':ZIP <br /> Free! En' APNO Lwo USEAPPuunoN/ <br /> I ai iso <br /> PHDHERI E[C BOS Da"FICT LOCATY)I OJ]E <br /> L-0 C5 <br /> IJS <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> /_/✓!'s J�/ CNECIt 1/81Ll1NG AD0RE5SLJ <br /> BUSINESS NAME —/lwP 'Iea"S E" . <br /> LI( <br /> HOME or MAILwo ADDRESS FUN <br /> CRY STATE ZIP - <br /> BILLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent or iemc t <br /> acknowledge that 8l1 SIIC end/or prOfM SpCCIRC ENVIRONMENTAL RGLTII DEPARTMENT hourly CIIaIgCS a55DLla[Cd WIIh IVIS pm1CC1' <br /> or activity will be billed to me or my business as Identified on this form. >Xj" <br /> RFI F,r' <br /> � ��Nr <br /> 1 also certify that I have prepared this application and that the work la be performed will be done in accordance with aIPSAN ID Gw <br /> CDUNry Ordinance Codes,Somdards,STATE and FEDERAL a - - c <br /> APPLICANT'S SIGNATURE: _ DATE: yT�$ <br /> PROPERTI'/BUSINESS OIVNERIJ OPEMIDR/MANAGER❑ OTIERAUfI10RIZP.n ALEM❑ ilY'�iY�l{ `�"'JO <br /> lfdPPlICdNPisnO/thell1LLIAGPAR1Y.proofafaa0mrizalion to sign is required ' Title ` ''. " !'/� �NV/R�`�1//y O - <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property IDcated�el the N ME NT <br /> QCT OEP N07 V <br /> above site address hereby authorize the mlease of any and all results, geotcchnicat data and/or environmenod site assessment gRTMF <br /> information to the SAN JOAQUIN COI ENVIRONMENTAL HEALTH DEPARTMENT as won as it is available and at the same lime it is NT <br /> provided to me or my representative. - - <br /> TYPE OF SERVICE REQUESTED: C^sy-\5 , <br /> LDYYENTS: <br /> ACCEPTED BY: ��,^ y� - - EMPLOYEEM DATE: —7 <br /> As9GNw TO: , ` e EMPLOYEES: DATE: <br /> Data Service Completed (Ifalhmdy woolleted): SERVIDECODE: 1 PIE: <br /> Fee Amount, - Amount Pa' Payment Date 11 C <br /> Payment Type Involeett Cheek I ZZ Recei d By: <br /> END RB-0$-025 SR FORM(Golden Rod) <br /> REVISED II/122DDD ' <br />