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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Type of Business or Property SERVICE PJEQUEST <br /> FACILITY <br /> ^ - ID# SERVICE REQUEST# <br /> OWNER/OPERATOR, 1 V 13 609X16 <br /> (ca �jFrnpn&-1 Ze4m O Z� <br /> FACILITY NAME CHECK If BILLING G=ppRE55� <br /> Tates C c jqtiTts �,w �j S <br /> SIT DDRESS .� <br /> Street Number Direction `-'w.��t L{� <br /> ' 1 � /' <br /> HOME or MAILING ADDRESS (If Different from Site Address) Street Name '-l1 <br /> CH Z Code <br /> 1l�P N Lrt <br /> CITY J Street Number <br /> I Street Name <br /> TATE ZIP <br /> PHONE#1 Exr, 1T <br /> APN# <br /> (111 .3(�3 y2b � LAND USE APPLICATION# <br /> PHONE#2 1 ` EM, <br /> ( ) ^ �, BOS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> CONTRACTOR / SERVICE REQUESTOR <br /> qq <br /> C tTi-'k �V r2V1% CHECK if BILLING ADDRESS <br /> BUSINESS NAM ('k- . r PHONNE# s ,3 Ex <br /> HOME or MAILING ADDRESS FAX# <br /> CITY <br /> re-11 r STATE <br /> BILLING ACKNOWLEDGEhIIENNT: 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 Coder,Standards, STATE an ERAL laws._ <br /> /j /1 <br /> APPLICANT'S SIGNATURE: D %��ATE: 1 b'O.2 Z <br /> PROPERTY/BUSINESS OWNER OPEpR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> 1fA,PpLiCANT is not the BILGWG PAR 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: Y40F <br /> COMMENTS: l eo <br /> FEB 2 21022 <br /> s I ,1 l e��OQUIN COU/y <br /> IV CV3 u HEA['TFIOI fT�1M'LL 1 <br /> ACCEPTED BY: L/` EMPLOYEE#: DATE: 2 y ZZ <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: PI <br /> Fee Amount: AmowkPai Payment Date 2Z <br /> Checki4 3 U �2 Received By' <br /> SR FORM tGOltlan Rodl <br />