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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE Rt-QUEST <br /> TYpe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0n �{-� 00 Zs 3 b ti��� 141 <br /> OWNER/OPERATOR <br /> � f \ CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �.� e1zt��, t r ��il L' Zi Code <br /> Street number Direction � <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number \ r t Strnet Name <br /> CITY , STATE ZP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PHONE# Ex r <br /> BUSINESS NAME �r`�} e;`'t 7 I-- <br /> HOME or(MAILING ADDRESS7 FAX# <br /> / { <br /> STATE t "'i ZIP <br /> CITY ` T 0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned propertN or business owner, operato►• or authorized agent of same. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HeALTrt DEP.ARTNIt:N'r hourly charges associated with flus ect <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared thus application and that the work to be performed will be done in accordance with all S.-VN JOAQ LN <br /> COUNTY Or- (ocle.t,Standarcl.�;�S"r, E and FEDERAL laNNs. ^ , <br /> APPLICANT'S SIGNATURE: �% tiles-u.L `�G,�}✓ DATL:O <br /> ` <br /> PROPERTY/BusmF,ss OWNEROPIsRATOR OTHER AUTnORIZED AGENT❑ <br /> JfflpPL1CANT is not the 811 Ll,V�1?f} Prov of authorization to sign is required 1'irl� <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the propert} located at the <br /> above site address, hereby authorirc t11e release of amv and all results, geotechnical data and/or environmental/site assessment <br /> information to the SA`JOAQUtN COUNTY ENVIRONhtP.NTAt,HEAL"I"tl DLY;112"TMf?NT as 50011 as it is available;►� ilx�s l[lNtinle it is <br /> proN ided to me or my representative. ]'�IIrI,�V <br /> 17 1J1 G 'ti. Fd <br /> TYPE OF SERVICE REQUESTED: 7 <br /> COMMENTS: �SA'NjQA <br /> ENV. QUI��C <br /> yEALTH QE pME7,4 L <br /> TMENT <br /> 0 N. - <br /> EMPLOYEE#: DATE: <br /> ACCEPTED BY: — -- EMPLOYEE#: DATE: <br /> ASsIGNED TO: SERVICE CODE: p I E: <br /> hetet (if already completed} — <br /> Date Service Comp Amount Paid Payment Date <br /> { F> taunt: Cheek# Received By: <br /> r q <br /> Invoice 4 <br />