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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S*qlw Qe a ' l Mc.,k.&� N-0-0 2211 $ S\'Z v1\�&() <br /> OWNER/nOPETRATOR <br /> -J!7_l �j J CHECK If BILLING ADDRESS <br /> FACILITY NAME SAV 1 U -L n <br /> SITE ADDRESS W �GSE'�I T� ,1'71/F tIL'(/'}y,J 7L CF) ` 13 <br /> L(20 Street Number Direction Street Name city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Si9te <br /> �C / e _ PsStreet Number Street <br /> Name / <br /> CITY [^ STATE ZIP <br /> PHONE#f Eu. APN# LAND USE APPLICATION# <br /> PHONE#2 EZT. BOS DISTRICT LOCATION CODE <br /> ( t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME n PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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. q <br /> APPLICANT'S SIGNATURE: /2C� —L DATE: t�/ <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT 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 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time Itis provided to me or <br /> my representative. I'�/�Y <br /> TYPE OF SERVICE REQUESTED: Cry <br /> COMMENTS: 31 20 <br /> IYAZnt O Ni Cou'v <br /> TA!@NT <br /> ACCEPTED BY: / Fa EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICECODE: P/E: `�� <br /> Fee Amount: * I SZ I Amount P ' sp,vD Payment Date 31 <br /> Payment Type (20— Invoice# Check# Received By: <br /> S <br /> OEHD 48802-025 PR <br /> ^`�I r� ( SR FORM(Golden Rod) <br />