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� (2, os0C) <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '4 C o `•t k oo- 1 '5 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FAciuTY NAME -- <br /> U�'l/� c- <br /> SITEADDRESS ZZZGI lr\J �G`( `1 0))V4 Ty-b C� <br /> Street Nurrber Direction I Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2 Z� �c�Mo l Gl W G1� <br /> Street Number Street Name <br /> CITY T r STATE Zip <br /> PHONE rr1 1� EXT- APN# LAND USE APPLICATION# <br /> Exr. EMAIL BOS <br /> PHONE`,u2 ]DISTRICT LOCATION CODE <br /> ( ) fic,�tr0(AC��l�dmC�' mG1II Ctrs <br /> _ I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS® <br /> G1 �Cf!IIG <br /> all <br /> PHONE# E R' <br /> BUSINESS NAME �� �� { � �I�I, �/-v',rl ; i } <br /> VvI I jFAXr <br /> HOME or MAILING ADDRESS -7—q,/„ � o rtD i o <br /> 'A// STATE ZIP /��z�'1� I EMAIL <br /> CITY QV`l. <br /> BILLING ACK WLEDGEMENT: 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 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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER W PERATOR/MANAG R ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT isnot the Br[_uNo PAR proof P <br /> roof of authorization to sign is required 7'r11e <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 environmentaVsite assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the same time It is provided to me or my <br /> repreSEntatNe. ,} Lam^ N7 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Sq NSEP 13 20?3 <br /> EN 04QUI <br /> HEqCOU <br /> �TH D ART �Nry <br /> N <br /> ERiPLOY�t#: DATE: <br /> ACCEPTED BY. p 1 223S.EMPLOYEE#: -A5 u DATE: "C'l� <br /> ASSIGNED TO: L as PIE: 2 <br /> completed): SERVIGECDOE v <br /> Date Service Completed (if already ): <br /> ent Date <br /> Fee Amount: ` '� �" <br /> Amount Paid ���,�d Paym � �3 <br /> By: <br /> G Invoice# <br /> Check# 14 g 733 SS3 Received <br /> Payment Type <br /> 7t� 1 �oC�) 3 3 g <br /> I <br />