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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bu iness or Property F17A 030-7(�S-() 'SK QDZW Ili 2--4 <br /> FACILITY ID# SERVICE REQUEST# <br /> Uf Y-1 <br /> OWNER/OPERATOR <br /> n CHECK if BILLING ADDRESS <br /> FACILITY NAME 0 A �l <br /> SITE ADDRESSS� — <br /> StreetNumber Direction Street Name �N Cit Zip Code <br /> HOME or MAILING ADDRTESSn(If Different from Site Address) <br /> X. I Street Number C Street Name <br /> CITY \ __ STATE ZIP <br /> PHONE#1 rl�1Y\• Ems. APN# LAND USE APPLICATION# <br /> (doh ) 2 1161 <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADORES <br /> BUSINESS NAME �uL ti i PHONE# EXT. <br /> 1 :o 1 t 1 1`;l� ) . 2 - �. <br /> HOME Or DDRE MAILING FAX# <br /> �s <br /> g � 42Yrc16Cr✓0 1 ) <br /> CITY sV — v ' 1 STATE ZIP 2 <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. }} '1 <br /> APPLICANT'S SIGNATURE: DATE:DATE: 1 L.1o zs 22 <br /> PROPERTY/BUSINESS OWNER 60 OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to the or my representative. p <br /> TYPE OF SERVICE REQUESTED: C Cis1,1.1 Z./SL\ EC <br /> COMMENTS: <br /> CkuVity 08 2072 <br /> JOAQUIN <br /> THDNMEAlTUNT y <br /> 0% NZAL T <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: I EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: U I PIE: O <br /> Fee Amount: - I S i Amount Paid I stir O� Payment Date / 22 <br /> Payment Type Invoice# Check# S 3 96, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />