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SAJOAQUINt uNTYL' NVllk0NNlEN�l'ALt1 AlirHI►E <br /> NPAxTNIEN7. <br /> SERVICE REQUEST <br /> -r pe of Business or Property '.FACILITY IDS#/ . SERVICE REQUEST#" <br /> ✓EN/cNGf . f^VRS �RE �-f" /I.DOCJ`�L�cT ar ' " �. i�1�OQ✓?O�o2a� " <br /> OWNER/OPERATOR /I1/C CHECK if BILLING ADDRESS❑ <br /> . <br /> FACILITY NAME <br /> 7- �LcVEtJ >Q 32180 <br /> $READDRESS !{-c��"3 S. P.T�, 9'9 FRoMTA,6e_ 50ct4-?aN 95'zl5 <br /> Street Number Direction Street Name cI ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) - <br /> Street Number Street Name <br /> CIN STATE - ZIP <br /> PHONE#1 Exr. APN# - LAND USE APPLICATION# <br /> PHONE#2 Ex. BOS DISTRICT " ' LOCATION CODE'r, - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - CO 7 �i/G/NEER/A/4 OA(S�C.77oti1 /��. CHECK If BILLINGADORESS� <br /> BUSINESS NAME - PHONE# Exr. <br /> 7G0 ) 721- ¢ryo <br /> HOME or MAILING ADDRESS FAX# <br /> /05 CovP oO GI�/ty S�//T7S G (74,0 117zr- 4 2-0 <br /> CITY ©GEA-NSI STATE Cit ZIP 9205¢ <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 <br /> 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,ST RAL law <br /> APPLICANT'S SIGN A � DATE:: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C7r <br /> /f 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 <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 DEPARTMENT 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: \. –, CLI -C <br /> COMMENTS: PAYMENT <br /> �(Dv-ejZ�1542. RECEIVED <br /> �c9�i iw � irl. i � -iUi_ 9 anJ2 <br /> SAN JOAQUIN COUNTY' <br /> PUBLIC HEALTH SERVICES <br /> =NVIROMA'MI4I.HEALTH OIVISIiFv <br /> APPROVED BY: - EMPLOYEE#: DATE: •�� <br /> ASSIGNED TO: . f, ... k: EMPLOYEE#: .r. DATE: <br /> Date Service Completed (if already completed SERVICE CODE: C PIE:2r�,,. :: <br /> Fee Amount:' -1/ Amount Paid Payment Date .- <br /> Payment Type ✓ Invoice#' ' Check# — u Re eiv d By <br /> EHD 4601-025 l JSERVICE REQUESTkORM <br /> REVISED 65412 <br /> s v <br />