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JAN JOAQU[N UOUNTY ENVIRONMENTAL HEALTH UEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> yy�'ye)�' Lr79 00oo C) F,00 +!5 <br /> OWNER/OPERATOR <br /> A a L,-,i� �I CHECK if BILLING ADDRESS <br /> FACILRY NAME �/ •✓1 �C v� <br /> ynr�k Is <br /> SITE ADDRESS N <br /> Sheet Number Directlon Street Name Zip CO& <br /> HOME or MAILING <br /> ��ADDRESS (If Different from Site Addre� <br /> L�'v E-ter Y A �� k- G Street Number <br /> CITY STAr,V� zip <br /> �C'r�-Cr1 C 4- c kS c 3 <br /> PHONE#I APN# LAND USE APPLICATION# <br /> PHONE 82 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> IREQUESTOR ( <br /> ��i iZ ��%��f� CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1, a \\ PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> 1 nv mcti., S ( i <br /> CITY STATE zip <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 <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 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: ��, ��I„�% +. DATE: <br /> PROPERTY/BUSINESS 0wNER)9 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPLIC4.WT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP.AXINIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I"/C, <br /> COMMENTS: <br /> r <br /> CX tvEc�1 VED <br /> APR <br /> sAN 2024 <br /> JOA <br /> NEgLTH ON .FNUNry <br /> ACCEPTED BY: ` ^— EMPLOYEE M DATE: Z <br /> ASSIGNED TO: r EMPLOYEE M DATE: / <br /> Date Service Completed (if already completed). SERVICE CODE: u I PIE: ! O a <br /> Fee Amount: L r/ Z Amount Pai ��� on Payment Date <br /> Payment Type Vi Ste. Invoice# Check# 'g)033Q/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �^ 0 1 (49 1 1(:�O <br />