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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVI E REQUEST#� <br /> OWNER/OPERATOR 5 <br /> F1:'N C CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> T4�t31e. i Zzp <br /> SITE ADDRESS -L,53 Al vQ 5-33G <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -111 6 P-(}N3> T E-rc N-1 'D P— <br /> Street Number Street Name <br /> CIN -T-i?-A C-y STAT ZIP S <br /> PHONE#f Ezr. APN# LAND USE APPLICATION# T <br /> 6160 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ezr. <br /> o c A N9 'fR6 e izzA 20 - gl 00 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY —_n P, STATE ZIP 'I S- <br /> Sri!'1 <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,Standard , STATE andLE.EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12 ID 2-12 n <br /> PROPERTY/BUSINESS OWNER❑ tr OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ �Q,GtCrRPF- <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required irte <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: <br /> COMMENTS: E <br /> DW �FC�ryED <br /> qI CQ? 2020 <br /> NEI CIV2 COU <br /> ACCEPTED BY: CA 1A/VC G EMPLOYEE M DATE: <br /> ASSIGNED TO: v1.n A/t n�,/1EMPLOYEE#: l DATE:00 <br /> I'y <br /> Date Service Completed (fValready completed): SERVICECODE: PIE. I2 <br /> i <br /> Fee Amount: 15 d''U� Amount Paid Payment Date 12 If2- ,ZD v <br /> Payment Type NWCIKInvoice# Check# 3 Received By.: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />