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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> rTypeZofusiness or Property i FACILITY ID # SERVICE REQUEST it <br /> OWNER / OPERATOR - <br /> CJ Z e�FL) 7 L CHECK if BILLING ADDRESS i <br /> FACILUY NAME <br /> SITE ADDRESS _ <br /> ` �3 Street Number Ulrrctlnn lie VO <br /> streez&ame / r <br /> Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) A) eLVIO <br /> Street Number t ^beet Name <br /> CITY <br /> AJ <br /> ` ✓1 �s _� STATE :QIP <br /> Pillow ttl Exr. APN #71 <br /> blow# I.,AND USE APPLICATION <br /> © _ <br /> PHONE 82 En BOS DISTRICT <br /> { LOCATION CODE-: <br /> CONTRACTOR SERVICE REQUT4STOR <br /> REQUESTOR gy� <br /> fe P ! r ! ,. d tI FIL) : 2 CHECK if BILLING ADDRESS <br /> BUSINESS NAME � <br /> A ea4n Loa d r'' ' , t ,� J ' - � XT. <br /> If`� <br /> HOME or MAILING ADDRESS <br /> Frtx # <br /> I CITY STATE zip <br /> BILLINr ACKNtJVtfLEDGEAIIENT: t, the undersigned property or business owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hOUdy Charq aSSOCiated With this project or <br /> activity Drill be billed to me or my business as identified on this form . <br /> I also cerdf)1 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�nd FEDERAL laws. <br /> N. <br /> APPLICANT 'S SIvNATURE : � r .< <br /> �r DATE: <br /> PROPERTY t BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT iS not the BILLING PART/ proof of authorization to sign is required Title <br /> <f AUTHORIZATION TO RELEASE INFORMATION: Nihen applicable, I , the owner or operaior of the property located at the above <br /> site address, hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided tjIl or <br /> Iny representative. I� <br /> TYPE OF SERVICE REQUESTED : � {��• ��� � � /�� <br /> COMraENTS: � � ; y&el c)/P f 4 !;! er' fZ f. C P ��j � Q (37Y Y t ° 7j(ir <br /> � 5 A4441WIJ 4 :e75 �P <br /> ti Fiy�/R Q�/N 9 <br /> Fp NT <br /> gRT�q <br /> ACCEPTED BY: \ T <br /> � • �N ER7PLOYEE. #: DAi F : �y <br /> ASSIGNED TO : � /� _ 2p <br /> • \ CW EMPLOYEE #: DATF: <br /> Date Service Completed (if already completed) : SERVICE CODE: 1 / q (g TI <br /> Fee Amount: Amount Paid �� b Payment <br /> Payment Type Invoice # Check <br /> 103 Received Bye.__ all, <br /> Pilo1 <br /> EHO 48-02-025 <br /> 0711 ? e ENVIRONM *WiU IfI n Rod) <br /> PEM ] 1T/SFR` /IrF <br />