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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# `1 <br /> h R Ile : Ha r ►+ FA 00 SROI»; 102-I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS Q <br /> FACILITY NAME r <br /> Sv.v r � « f5 �p� c� .c.F 54,rr I <br /> SITE ADDRESS Iyh 00 1„� f'f W tg / � els--t-4/Z <br /> street Number oireCron 7 Sbeet Name CitvZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 5 eel Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ()051 )--o s oc :75 10550301 `7 <br /> PHONE#2 Ex, SOS DISTRICTLOCATION CODE <br /> ( 101 ) 62` 2 b ®�` q�q <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> FT t <br /> d C 4 I CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> rv./th .. Re �,Fs � �rrl s < -r� <br /> HOME or MAILING ADDRESS FAX# <br /> 1q,100 W ( ) <br /> CITY ` ; STATE ZIP p1 r- 1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> aclmowledge 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 d the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,.' ,an RAIL laws. <br /> APPLICANT'S SIGNATURE: DATE: O q/2. <br /> PROPERTY/Busts OWNER 13 O ett 'rOR/MANAGER LJ OTTTE.R AUTHOTJ eD AGENT❑ <br /> If APPLxAYr is not the LINGPART proof of authorization to sign is required Tate <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: ///��� /1 -�^ ^ �� <br /> COMMENTS: C'N ,•r._, Of' OWI'Wr t4/' P - OJ A/�P ED <br /> t1Y�( te( f SgNJ R �� ZQ?� <br /> Oq <br /> HEgCTH IDEp4R//N7-4�NTy <br /> ACCEPTED BY: EMPLOYEE#: DATE: —� <br /> ASSIGNED TO: EMPLOYEE M pAm; <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: P O Z <br /> Fee Amount: / Amount Paid <br /> a. btT, Payment Date � <br /> Payment Type 'sem Invoice# Check# Receive B <br /> /L g Y: <br /> �9k$�$?{B �IES�tA19LstSl <br />