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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT o <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -71%.6 <br /> OWNER �q <br /> OWNER/OPERATOR <br /> r,r 9r /yJ-, CHECK If BILLING ADDRESS <br /> e�1L ""'J <br /> FACILITY NAME <br /> �NtT\ wcQ \�H.tS <br /> SITE ADDRESS <br /> {LL G/ <br /> 7 Street Number I Direction Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site AddrrpesGss, �owst <br /> Street Number `� Street Na <br /> CITY \_ `' STATE (—A ZIP <br /> PHONE#1 r �r• ExT' APN# LAND USE APPLICATION# <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR W CHECK If BILLING ADDRESS <br /> e_ryL V/� <br /> BUSINESS NAME PHONE# E�T- <br /> �v pti 5 - 3o7N <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 'ill V u y,\� STATE �� ZIP '36� <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,Standar TE and FEDERAL laws. 1f <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Iff1PPLICANT 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 GyouNrY 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: wt\ vi t o �tt�f{� gel,Y I G v A\I c <br /> COMMENTS: /`/CD <br /> sq JUN 0 2 202`1 <br /> EN�OgQUI <br /> NEgLTH OC p�EN7a NT y <br /> ACCEPTED BY:' EMPLOYEE M 2/I DATE: 0 <br /> ( <br /> ASSIGNED TO: / f EMPLOYEE M DATE: `V <br /> Date Service Completed (If already com, eted): SERVICE CODE: '� P 1 E: <br /> Fee Amount: GAmount Pal to(0DD Payment Date <br /> Payment Type C �l�S invoice# /D n 11p Check# �(j3(0�� �63 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 v <br />