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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR KS TanA r V(/, JA CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> tit A � �'� ri �3 <br /> Street Number Direction Street Na mo Ci Zip Code <br /> HOME or MAILING A DRESS (If Different from Site Address) a <br /> Street Number I,` Street Name <br /> %J <br /> CITY l� �1 STATE � ZIP <br /> PHONE#'I l E., APN# LAND USE APPLICATION# <br /> (70 ) 3(3 4- 5 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR rl, _1 I r� �, <br /> 61 CHECK If BILLING ADDRESS <br /> BUSINESS NAME It/1 ' �, en PH NFF.# �( � I� EXT. <br /> HOME or MAILING DDRESSFAX# `(S <br /> k vJa ( ) <br /> CITY t le-) —1 <br /> STATE ZIP 04S-3--L) EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or projects <br /> pecific NVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or activity <br /> will be billed to me or my business as identified n this form. <br /> also certify that I have prepared this licatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TA and EDE AL laws. <br /> APPLICANT'S SIGNATURE: DATE: 6 � ' <br /> PROPERTY/BUSINESS OWNER❑ O ERA T / ANAGER ❑ OTHER AUTHORIZED AGENT ❑ ! <br /> If APPLICANT is not the BIL G R proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATI N:When applicable, I,the owner or operator of the property located at the above site: <br /> address, hereby authorize the release of any a d 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 t0 me Or my' <br /> representative. pp�� <br /> TYPE OF SERVICE REQUESTED: OFF CQY1SLJ,+rj-r vn 7/F <br /> COMMENTS: <br /> 9 <br /> &A,,Uw CO <br /> cryo pqR �N�, <br /> ACCEPTED BY:b Y Ianvie M. EMPLOYEE#: DATE:"3'2Ct t ZtDZq <br /> ASSIGNED TO: EMPLOYEE#: DATE: '312q'2ZLq <br /> Date Service Completed (if already completed): SERVICE CODE: Q(v P/E: <br /> Fee Amount: (02.ov Amount PairICLDb Payment Date 2 2 <br /> Payment Type Invoice# Check# 17g 12DO-7eceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22123 <br /> P12, DSI9oI-4-- <br />