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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �1 fiPr Oo 2s 2 S� 'Q X09(oS 2 <br /> OWNER/OPERATOR CHECK If BILLING ADDRE$S0 <br /> 511 �Ta�ncA -- <br /> FACILITYNAME'e)O ��,/t�'\� Wop <br /> SITE ADDRESS X�' S Y� <br /> eel Number Directiontree Name `l t G �'1 ZI Codn <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> StlreYet Numhet \v Street Name <br /> zip <br /> CITA'`r��1 IO `TATE <br /> PHONE#1 Ell APN# LAND USE APPLICATION <br /> tea) <br /> C1 C1 — --- - <br /> P2 Ezr l BO$DISTRICT LOCATION CODE <br /> W `ASO' $18 u ►� \�+ �o — <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> REOUESTOR <br /> TaV10 QQ CHECK,if B LL ING ADDRESS <br /> BUSINESS NAME PHgE# e.r <br /> HOME or MAILING ADDRESS Fax# <br /> Am c � <br /> CITY-V-y'-e Y D STATF(P, ZIP Ct3l2 EMAILSN �iA1 <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 or activity <br /> will be billed to me or my business as Identified on this form <br /> I also certify that I have preparedthis applica nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes Standards. Sr andDERAI laws <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER E OPERATOR t MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If A-_ -is not the BftoNG PARTY, proof of authorization to sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable. I.the owner or operator of the property located at the above site <br /> address,hereby authorize the release of any and all results.geotechnical data and/or environmentaUslte assessment itifo i��py�to the <br /> SAN JOAOUIN COUNTY ENV.RON!.+ENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it IS prOVldr)�� e_,' /� <br /> representative /rT C ''vv <br /> TYPE OF SERVICE REQUESTED: f `�� b v V JT l JIJAI fit <br /> COMMENTS: SqN OZ? <br /> EN�AQ OUIV <br /> N�ALT NCIIN <br /> DS A6AI r4 <br /> I <br /> R Elvi <br /> IN <br /> ACCEPTED BY: yz 1 EMPLOYEE#: `�� DATE: Z <br /> ASSIGNED TO: C EMPLOYEE#: DATE: 1� <br /> Date Service Completed if already completed): r SERVICE CODE: 061 PIE: <br /> Fee Amount: Amount Paid / Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48.02-025 SR FORM(Golden Roo) <br /> 03r22,,23 S <br />