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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA O OO z-LL-( (:) '5e 002 Z l 2-4 <br /> OWNER/OPERATOR �/ 1 <br /> �� a� LI��� CHECK If BILLING ADORESS� <br /> M <br /> FACILITY NAME 1 "l C(/`J �IT --tr`_` � <br /> SITE ADDR1f.,SS ' I 10,ftelr �n ��tlG � P q�/� <br /> 6l Street Num bar (D/i\rJe:UoStreet N. a CI Zip Code <br /> HOME or MAILING ADDRESS (If Different fSlto Address) {''66t,) <br /> dY <br /> Street Number V Street Name <br /> CITY 3 / )C/ STATE c1q ZIP t`C'21\ <br /> PHONE#t '(��/ ! EXT. APN# LAND USE AAPPPLICATION# J (� <br /> ('�Oy) -77 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /1 <br /> N '\IVl ClMP(j dglncL r.t r <br /> I`� LV L�. CHECK It BILLING ADDRESS <br /> S+Oc 1 r) lUC' U �litY 4 r app 3�d ER. <br /> BUSINESS NAME PHONE# <br /> HOMEO�MAILING ADD ESS , FAX# <br /> all ( ) <br /> CITY �1 0c'k 4e)A STATE C/4 ZIP qS-2/6 <br /> BILLING ACKNOWLEDGEMENT: 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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, STATE and FEDERAL laws. <br /> 0PPLICANT'S SIGNATURE: DATE: S/-G �t <br /> PROPERTY/BUSINESSOWNER OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> I,fAPPLICA 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. P <br /> TYPE OF SERVICE REQUESTED: -T-00d// 1 c e RF '•T <br /> v <br /> COMMENTS: /1�u�� 0 ��� b� MA►'2 9 <br /> S fp ogQUIN 2020 <br /> N ' DEPgR ill <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: o m EMPLOYEE#: DATE: <br /> Date Service Completed (ifalready completed): SERVICE CODE: OLP P I E: <br /> Fee Amount: ��2, pQ Amount Pa( /S,2 Q I Payment Date `j 2 <br /> Payment Type Invoice# Check# Received By/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> wo 1 -025-1 0 <br />