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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> pF o ocl T12 v c IL (<,� 00I � l <br /> OWNER I OPERATOR ` <br /> CHECK IfBILLIN�SSE3 <br /> FACILITY NAME 5 ` O � <br /> SITE ADDRESS 1� i � `` __ <br /> ` � � 1 pillla lY `� 5 o CII ZI Code <br /> S Number Direction Street ame <br /> HOME or MAILING ADDRESS ( If Different from Site Address) I.1 .0 e 11 . J <br /> ✓ R 5, Pc H I ` IJ or Ii Street Number Street Na e <br /> CITY S k a. � Awl STATE cx I � Z 12 <br /> PHONE #1 �cJ ExT• APN # LAND USE APPLICATION # <br /> s9R - � szq <br /> PHONE #2 ExT• 130S DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORCHECK if BILL;ppING ADDRESS <br /> - <br /> P 1 \\i <br /> Ext. <br /> pl <br /> BUSINESS NAME PHONE # <br /> Lill <br /> HOME or MAILING ADDRESS FAX # <br /> /A nt Smile � <br /> CITY 5 OL Lo ,�/ STATE G ZIP of S Z ( 2 <br /> BILLING ACKNOWLEDGEMENT : I, the undersigned property or business ol operator or authorized agent of same , <br /> acknowledge that all site and/or project specific EIvIRoNMENTAL 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 . <br /> 7 <br /> APPLICANT'S SIGNATURE: DATE: / / Z o Z <br /> PROPERTY / BUSINESS OWNER OPERA AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLiCANT is not the &LLING 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. <br /> TYPE OF SERVICE REQUESTED : p) E ✓U J C <br /> COMMENTS : /In <br /> RFCOwlF� N 7` <br /> ,SEP 0� ` � <br /> Sq 2020 <br /> N �Oq <br /> NEq�tH 0NMENOUN7`y <br /> ACCEPTED BY: L l t% twt EMPLOYEE #: <br /> DATE: EM7Tpill <br /> ASSIGNED TO : C� le I, If G EMPLOYEE #; <br /> DATE: - _ <br /> Date Service Completed (If already completed) ; SERVICE CODE : <br /> Fee Amount : Amount P� c1 -rZ P i E : <br /> fl <br /> Payment Date Ga <br /> Payment Type � 1 Invoice # Check # <br /> ReceiRUNved By : <br /> EHD 48-02 -025 ( <br /> REVISED 11 /17/2003 C- <br />