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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n i 7 -3 z- <br /> -OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> - 'FACILITY NAMEC-h <br /> o ton <br /> SITE ADDRESS �yl/. Map y)ry� f ,•� I ? T�� <br /> Street Number Direction l�5tt-rjeetlNCaJmo l city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> ITY- - - - STATE ZIP ' <br /> PH NE#1 _ T' APN#gG LAND USE APPLICATION# <br /> GuIl ; g - ocn 0 O O.z <br /> - PHONE#2 _ ExT• BOS DISTRICT i?,h OCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I'[l CHECK If BILLING ADDRESS <br /> BUSINESS NAMEI PH NT <br /> 91-(0 <br /> HOME Or MAILING ADDRESSFAX# <br /> 2535 C1J%w `tL ( ) �i-mom <br /> --. --CITY STATE Op ZIP qcp <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 preparedthis 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:. ' 'Iw , wo ll ' DATE: <br /> _ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L]I T L•P t�1 P�UI IU tI�J O� <br /> If APPLICANT is not the BILLING RIR TY 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 COTINTY 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: <br /> JUL 16 w_ <br /> _ SAN JOAQUIN COUNTY <br /> _ ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ERE&IPLOYEEM DATE: �(p / Z <br /> ASSIGNED TO: 7PLOYEE#: <br /> DateService Completed (if already completed): SERVICE CODE: - PIE: Z3d <br /> Fee-Amount: Amount Paid '' _ „!' Payment Date (f <br /> ` aTtent Type_ I L Invoice# - Check# { '7 Received By: <br /> J48-02025 . : <br />