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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OPERATOR CHECK if BILLING ADDRESS❑ <br /> lv <br /> F TY NAME C1 V it <br /> o ` '� l I C ti v'Ct L <br /> §j14,ADDRESS _ ��s vv n I W IC � . <br /> Street Number Direction \ Street Name Ci iy Code <br /> NIE or MNG ADDRESS (I Different from Si _ddress) 1 ec / <br /> U Street Number Street Name <br /> PTY STATE zip <br /> Icc Acyk . <br /> PANE,#1 EXT- APN# LAND USE APPLICATION# <br /> PHONE#2 !� EXT• BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> 59QUESTOR — <br /> L� CHECK If BILLING ADDRESS <br /> DIMNESS NAME , <br /> � � PHONE# , EXT. <br /> C' C Ct `��'S G'v V 1 <br /> ( DME Or MAILING ADDRESS FAx# <br /> C 1 ) <br /> CITY :s c. S TE I 7.� . <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 1�2— _CN_ „2C)2j . <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT 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 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: I,tit�.� v�S (�L V ,�~~• �� <br /> COMMENTS: D <br /> J 20 21 <br /> E 0AQUIN <br /> C��7y <br /> F <br /> ACCEPTED BY: EMPLOYEE M DATE: 2 L� <br /> ASSIGNED TO: V'r l V EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ` P 1 E: <br /> Fee Amount: I Z O Amount Paid 5 � Payment Date L� <br /> Payment Type ' Invoice# x'wC-Tc# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />