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,u h N{pa,)wtltzz ?OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business-or Property FACILITY ID# SERVICE REQUEST# <br /> �v t)\—AJ- <br /> OWNWL QPERATOR, <br /> CHECK H BIwNG ADDRESS❑ <br /> e <br /> FACIUW NAME <br /> SrrEADDRESs ula OCtL�� �Y�1 o���Q X15330 <br /> Street Number' a C Cede <br /> HOME or MAILING ADDRESS (If Dwerem horn <br /> Site Address) <br /> U \ \ Street Number she& Name <br /> CrfV STA ZIP <br /> PHONE#1- .Er. APN# LAND USE APPLICATION# <br /> ( ) L1 -- <br /> PHONE#2 1T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR T CNEOK'd BnuNGAoDR=13 <br /> BUSINESS NAMEPHONE# ' <br /> 8 <br /> HOME or MAILING ADD' FAX# <br /> �� ( ) <br /> CITY ST� 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 rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERA S. <br /> APPLICANT'S SIGNATURE: DATE:17 yl7 D 77� <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR NAGER ❑ OTHER AVI'HORIZED AGENT 13 <br /> If APPLICANT is not the / P ry proof of authortzation to sign is required rifle <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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available t the same time it is <br /> provided tome or my representative. <br /> TYPE OF SERVICE REQUESTED: CE <br /> Comma": 4 <br /> ". 0 NM 7r <br /> �/N <br /> � 71ip��AL <br /> ACCEPTED BY: .! EMPLOYEE#: DATE,:� <br /> ASSIGNED TO: F ` EMPLOYEE#: DATE./` <br /> Date Service Completed (N already completed): SERMCE CODE: -TP I E: <br /> Fee Amount: �6AAS�Q , 00 1 Amount Paid `IvJU r Payment Date Q I2LJ12 O <br /> Payment Type Invoice# Check <br /> # Received By: <br /> EHD 5 'O ( ` SR FORM(Golden Rod) <br /> REVISED 11/17Y2003 <br />