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r <br /> # <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Suslness or Property FACILITY ID# SERVICE REQUEST# <br /> C 19a <br /> OWNER I OPERATOR },, <br /> V 1 \�e rrl CJ- CHECK if BIWNG AouREss <br /> FAcam NAME TzV ,c' Ba" <br /> :� �� CA C <br /> SITEADDREss ` ` 150,-40 F- e-, 4V 1 c Sf Lo I <br /> Shoe!Mumbo 61ecUoe Street Naaw city ZIP C608 <br /> HOME or Mum ADDRESS (If Different imm Sita Address) <br /> Sheet Number Strad Name <br /> CITY STATE ZIP <br /> PHONE 91 E"* APN# LAND USE APPLICATION# <br /> y151 Lt0 4 G194 <br /> PHONE N2 Exr. BOS DISmar LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - /� <br /> cxr-cK if OrwNcs ADo�ss v <br /> BuswEss NAME. PHDNE# � <br /> V O�e�f Q Y1Gl C Ol d qi q q 4- S i "114 <br /> HOME or MAILING ADDRESe FAX# <br /> 2 9 VI00e 1 l <br /> CITY ck t STAVEel+ LP J <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 ENVMONMEt TAL 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 Codec,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATIME: " j CA_ DATE [ 1 Z-0 2A <br /> PROPERTY I BUSINESS OWNERgf a ERATOR/MANAGER 13 OTHER AUTHORIZED AGENT D <br /> IfAPPLICANT,is`not theBILLINGPARTY 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 DEPAPTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. jj � <br /> TYPE OF SERVICE REQUESTED: W l� h-(G <br /> PAM E- <br /> REGENIF <br /> cow mwrs: <br /> JAN 12 202 <br /> SAN JOAQUIN COU Tr <br /> EWRONMENTA <br /> HEALTH DEPARTM T <br /> ACCEPTED BY: EMPLOYEE#: DATE: r <br /> AsmeNED To: RA W r -Z EIMPLOYfE#: DATE: r <br /> Date Service Completed (if already completed): &WCECODe: s Z~`3 P I E: <br /> Fee Amount: Amount Paid Payment Date 1 <br /> Payment Type Invoice# dog t j 1� Received By: <br /> ��agLe410 <br />