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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />T <br />CONTRACTOR/ SL+'RYlc;E xWuLaiU <br />FACILITY ID # <br />SERVICE REQUEST # <br />•'REQUESTOR \ 1 <br />CHECK If BILLING ADDRESS <br />Ch1 j <br />Yd1au`C1tZ <br />BUSINESS NAME <br />OWNER I OPERATOR <br />BILLING <br />\\ <br />(i S'T�/AY\ <br />pp <br />(JIpNpGZ <br />CHECK If AGGRESS <br />FACH.m NAME <br />` <br />) <br />e <br />SITEADDRE$$SAY. <br />zip <br />' q \SZ <br />Street Number <br />Direction <br />Street Nama <br />city <br />ZI code <br />HOME Or MAILIHO ADDRESS (if Different from <br />Site Address) <br />J <br />js\?� <br />Stmet Number <br />SlroetNamo <br />tt <br />C S4oe �av <br />STATE ZIP <br />A <br />PHONE41 Pxr, <br />APN# <br />LAND USE APPLICATION# <br />(I ly) q2z�, 3384 <br />PHONE#2 Ex*• <br />BOB DISTRICT <br />LOCATION CODE <br />$TEEING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autlmrized agent at same, <br />L HEALTH DSPAaTMeNT hourly charges associated with this pro <br />x <br />•'REQUESTOR \ 1 <br />CHECK If BILLING ADDRESS <br />C.Yld1ST0.Vt <br />Yd1au`C1tZ <br />BUSINESS NAME <br />PHONE# <br />HOME or MAILING ADDRESS <br />FAH# <br />U� <br />ace56 .'C 3 2( <br />) <br />CITY S,�_ 1„\ <br />STATE ce, <br />zip <br />' q \SZ <br />-acknowledge that all site and/or. project specific ENVIRONMENTA <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 w rk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, SeA'• and FEDERAL law . <br />APPLICANT'S SIGNATURE: ' ' - <br />DATE: p S o2 202 <br />PROPERTY/ BUSINESS. OWNER OPERAT RI MANAGER 11OTHER AUTaomzED <br />AGENT 1:1 m <br />ject <br />IfAPPLICANT is no[!l7E BILLING P.1RTY, proof ofauthorization to sign is required <br />TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pr <br />AU'pH0release of any and all results, geotechnical data. and/orenvironn <br />above site address, hereby authorize the <br />infolmation to file SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and <br />provided to me or my representative. <br />EHO 49 -OZ -025 <br />REVISED 11 /1712 0 0 3 <br />SR PORM.(Golden Rotl) <br />