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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST JP r?-l$ <br /> Type of Business or Property FACILITY ID# SERVICE REQUESST# <br /> ' kCAUC,J [Cf, tYCI,JCV- SI'? oS <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> U5 CCA J 05 ,I �C511 <br /> SITE ADDRESS ► '6 _ <br /> Street Number Direction Street Name CI 2i Cotle <br /> HOME or`MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> J V 1 t 1 / v � CHECK If BILLING ADDRESS <br /> BUSINESS NAME J PHONE# Err. <br /> CA S ( ! <br /> HOME Or AILINGADDRESd FAX# <br /> 0 5 ( ) <br /> CITY L L k 4 <br /> 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 <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. t <br /> APPLICANT'S SIGNATUR14– 1,%S � I[Alis DATE—4 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT it 1101 the BILLING PARTY pr0of of authorization t0 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 tine it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Ee <br /> COMMENTS: ED <br /> Q ZROAf4fQ2022 <br /> QUIIV D771 <br /> OWN <br /> Ty DpARMN n <br /> ACCEPTED BY: EMPLOYEE M2f DATE: )-( ( t( r Z 4 <br /> J <br /> ASSIGNED TO: EMPLOYEE#: L O DATE: � ( f •Z2 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 4-U <br /> I ] <br /> Fee Amount: ( �'� Amount Pal*, /��,�� Payment Date // L J <br /> Payment Type $ Invoice# t Check# Received 8y: <br /> EHD 48-02-025 � SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />