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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA00 26250 SPIMB-9Bq co <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> 3u S r u v <br /> C1 Lt S FACILITY NAME <br /> r <br /> SITEADDRESS f�)1 '�� S f�ec t. /ti') LS �� co <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) < �✓C S SC' <br /> 5-5 Street Number ! Street Name <br /> CITY STATE ZIP <br /> S C� c C <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (?vi) 5 '� - is 2 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR //�� / <br /> y L r y l o f //r n CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME ���-ff `I �'1 PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> S S C cK U• ( ) <br /> CITY STATE ZIP Gj'�—. / EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or bul/siness 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: ��, DATE: �'� Z <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <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. pP <br /> TYPE OF SERVICE REQUESTED: COC1S 11 \kC,,�i0'n RE '•T <br /> COMMENTS: ^ I? <br /> ^i/_ 7 <br /> sgnrJO 2424 <br /> HFq 0NM�C7A tV ry <br /> h CEPgR MEAT <br /> ACCEPTED BY: � ;Ghne M , EMPLOYEE#: DATE: L+k4j 2-4 <br /> ASSIGNED TO: L� EMPLOYEE#: DATE:t4IU``Ly <br /> Date Service Completed (if already completed): SERVICE CODE: Q)(o, PIE: I tom3 <br /> Fee Amount: $�� 2 .mm Amount Paid (� Payment Date —f 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> 03122123 <br />