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- JAINJOAQUIN l UNTYLNVllt(li NIEN''IAL tlEALTH YAR'ITYIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> //�_ � <br /> •/7N✓EArICNG.E �p/1S JTORe� r r7' nf�� 3 4, e�Jle F: <br /> OWNER/OPERATOR <br /> 7- OtvcN /NG, CHECK If BILLING ADDRESS <br /> FACILITY NAME �^ <br /> 7- c Lc✓Eh/ � 3 2'go <br /> SITEADDRESS x}943 5_ RM. 99 .FROiOTA-G�. Srbcv--rbM 9S'Zt5 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY - STATE ZIP <br /> PHONE#1 Ear' APN# LAND USE APPLICATION# <br /> PHONE#2 Exr• - BOS DISTRICT ' LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / //�,, <br /> �A/!i//VC EK/MG Qi aA(S�G770AJ //AGS CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE#7Go 0cr• <br /> 72l- 'flZo <br /> HOME or MAILING ADDRESS . // FAX# <br /> /05 ( )7z!- *2-0 <br /> CIN ©GEhNS/p Z STATE CA ZIP 9ZO6+ <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,SjA3 RALlaw <br /> APPLICANT'S SIGNA ��`�� DATE: 11111,97- <br /> PROPERTY/ <br /> 11910iPROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT F5 (! A1710,Q-C TIC-1- <br /> IjAPPLICANT 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 environmentallsite assessment <br /> information t0 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: <br /> COMMENTS: Nif- V <br /> SAN.IUAGUIN CU�I'1 <br /> �'LBLIC HE41111 SFRNCE: <br /> APPROVED BY: EMPLOYEEM DATE: <br /> ASSIGNED TO: . EMPLOYEE M 2 f <br /> �- (C) DATE: <br /> Date Service Completed (if already completed): - SERVICE CODE: Cl PIE:Z K' <br /> Fee Amount: _ Amount Paid 1 Payment Date . <br /> Payment Type Invoice.# Check# 1 %7� Received By: - <br /> EHD 46-01-025 NJ SERVICE REQUEST FORM <br /> REVISED 6-5-02 - <br /> • <br />