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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PL o \ L- Ib <br /> Type of Business or Property FACILITY ID# C �SERII E REQUEST# <br /> W Q 00 9 SIioP F P1 C)0 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> f� JTAf'� SiN(�N Ki-IiN�A <br /> FACILITY NAME <br /> P ETOS L,I (A)U O RS <br /> 202 tj i 1 5376 <br /> I <br /> Street Number Direction Street Name CI Zi Code <br /> SITE ADDRESS <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> IAS SHP— Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c2c�-- 833-q ZSS <br /> PHONE#Z EXT. EMAIL DISTRICT LOCATION CODE <br /> P''—fes Ltl 00"q-)A ntail� �BOS <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP EMAIL <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 /> 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: A tit is C ,;;d,,, DATE: <br /> PROPERTY I BUSINESS OWNER;9 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY, Proof of authorization to sign is required Till e <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 environmental/site 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 /> representative. <br /> TYPE OF SERVICE REOUESTED: rllrAE�CF <br /> COMMENTS: A e.�gr18 e. o L c)W n e Ir JYl l p I 11S p�,t1 oo i jv/jut,SqN,, 32023 <br /> 0 <br /> HEA T D�pg6NTOq�NTy <br /> R TMFNT <br /> ACCEPTED BY: L ����� EMPLOYEE#: ::: DATE. <br /> ASSIGNED TO: e EMPLOYEE#: DATE: (" _ 0-00-2`i" _23 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: ` S 6 Amount Paid 5 Payment Date (C_ <br /> Payment Type ce- Invoice# Check# Recelved By: <br /> —7—7 0'� 11 <br />