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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> v <br /> CHECK HBILLING ADDRESS 13 <br /> 5o—r' pub ), ( <br /> J J' v(J <br /> FACILITY AAME V <br /> / � /-CQC/1 <br /> SITE ADDRESS �.V, 1 o- rp c -d s"'I /r LV yt <br /> Sy% Street Number Direction I ' 9 a1 N me f pC(C ( Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) q q /0 4 ' Su•}e I OJ <br /> Stmt Nubu 0 l p{aC Fie/ 1 <br /> mStreet Name <br /> C STATE ZIP <br /> 6f��Grl C'� �o <br /> PHONE#1 / yG L, APN Ik PBOS <br /> D USE APPLICATION t! <br /> (Qo ) ' "—q I— ho <br /> PHONE#2 Exr. DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / CHECK N BILLING ADDRESS <br /> BUSINES NAME, <br /> 1"t ©J 1 1 /r PHONE# Exr• <br /> HOME or Moa G ADDRRESS �J FAx# <br /> (>O oL°0r� Ave , SJt4— (QJ ( l <br /> CITV0AV1A ( 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 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,Standards, STATE and FEDERAL laws. �7 <br /> APPLICANT'S SIGNATURE: 6� � ` YAJ4 DATE: ` �1 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN40 <br /> 1f APPLtCANTisnotthe BILUV(7PARTY.proof of authorization to sign is required rTirt <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pr 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 s <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: , Vtk E� <br /> COMMENTS: Alt <br /> 0 <br /> SAN�� <br /> O 20 <br /> F /AQU/ <br /> hEA Tye PART.L uA TY <br /> ACCEPTED BY: EMPLOYEE DATE: 1 •�I. <br /> ASSIGNED TO: EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVI:ECODE: P 1 E: <br /> Fee Amount: 4 J Z Amount Pai l5� Dd Payment Date 8 [{ <br />