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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 15izoogn(05 <br /> OWNER/OPERATOR <br /> CG k, C r�e h CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME v I i— <br /> SITE ADDRESS ZI) .S� Z–/4ck h 1) S-Z 3 (o <br /> 5 Number I ni on S~Name CKV Zip Code <br /> HOME or 9AILING_ADDRESS (If Different from Site Address) 2 j) y Sc� r <br /> lI I L Street Number �Street Name <br /> �� <br /> CITY L G�� STATE/7` <br /> PHONE#1 En. APN# ` LAND USE APPLICATION# <br /> (L0`) ) � z3 = �� ay <br /> PHONE#ZEXT• BOS DISTRICT L LOCATION O <br /> ( 7- I ) 79 3 1 yG <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I_ II <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> EXT. <br /> loci LD' - Y D C/ <br /> HOMEor MAILING ADDRESS FAX# <br /> 2 y S-y C�'�rM 0r-e- 4 L-e-- ( ) <br /> CITY A,-) vl ��� STATE C 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 ano FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 1��2'�/ wee DATE: C' Z-/ <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT P <br /> IfAPPL/CANT 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 JOAQUYN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ^^// 1 <br /> TYPE OF SERVICE REQUESTED: So S u+}ab+ qN U iV 1 raI Loci �fVv Rey�p i„/PAY/ <br /> COMMENTS: hC� O� jer" �eiwidrde� 0/C/ C,(yrjlFsS 3V NQpj. RECEIVE <br /> OCT 21 202 <br /> SAN JOAQUIN COUN ry <br /> ENVIRONMENTAL <br /> HEALT DE T <br /> ACCEPTED BY: EMPLOYEE#: DATE: JC7 a 0 0 d O <br /> ASSIGNED TO: Ss EMPLOYEE#: DATE: p d I/;O,�b <br /> Date Service Completed (if already completed): SERVICE CODE: C� PIE: 0/L <br /> Fee Amount: Amount Paid — Payment Date <br /> Payment Type Invoice# Check# Received By: <br />