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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REE,iQUEST# <br /> v W L5 J KM 00�S' 13-I- <br /> OWNER/OPE AOR <br /> _ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS60 <br /> Stre¢t Numberireotlon t'1 Street Name JZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYV `a l e c 1 STATE ZIP S <br /> y 26 1 <br /> PHONE#f Ezr• APN# LAND USE APPLICATION# <br /> 2.1)N _ 6'b _ g <br /> PHONE#2 Y ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I ' <br /> _ vQ(t CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EX. <br /> M Q u S ( - E5"o <br /> HOME Or MAILING ADORES FAx# <br /> ( ) <br /> CITY ` C-g STATE ! p,, ZIP C <br /> BILLING ACKNOWLEDGEMENT: I, Hie 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. 11 <br /> APPLICANT'S SIGNATURE:JE7 -X Ir `Z�" Z <br /> PROP EITPY/BUSIN ESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT[I <br /> If APPL/CANT is not the BILLINGPART) proof of authorization to sign is required Tirfe <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, f,, PA)WEAFT <br /> TYPE OF SERVICE REQUESTED: ( Vt1 vt V LI ck,( I (/)S "EcelIvEn <br /> COMMENTS: <br /> Mori -�►2t 23 . 30a� CT 25 2027 <br /> ENVIRONI N COUNTY <br /> HEALTFI NZAL <br /> DE ART NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: IO 2S ZZ• <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0I P/E: I LU <br /> Fee Amount: Ica — Amount Paid Sl, O Payment Date /9y v <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1MU Ati <br />