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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Lr voR �G�/: ��0 �1� 12-1 SRoo`I5�1� <br /> OWNER I OPERATOR 11�rf <br /> 3111/ ^�[ / / /I CHECK if BILLING-,ADDRFSSI� <br /> FACILITY NAME ,IN' Cyt nJt�l/e Z Qn <br /> SITE ADDRESS 9/6 0 /V THA /V/jTO k✓l / L lrc <br /> I 1�Tock7ow Gr�o� <br /> Street Numb¢r plrecNon r. [Name CIN ,C�R Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> E i fiY <br /> Street Number Street Name <br /> CITY S.TAT^EE ZIP <br /> ... USE <br /> PHONE#'I EaT� APN# LANDD USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ex-.. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQ UESTOR <br /> REQUESTOR r/ <br /> Il � �— l \ , CHECK If BILLING ADORE55 <br /> BUSINESS FJ I` JEx . <br /> Q I �Uf9/ R / / CIyIL� L I y�I�/` P9/CE# 40 9yS i/ <br /> HOME Or MAILING ADDRESS FAX# <br /> 5 x � T 40) - 1 c > <br /> CITY i' o STATE ZIP <br /> BILLING ACKNOWLEDGErtriENT: 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,STATE and FEDERAL laws. <br /> APPLiCAN T'S SiGNA T URE: h P 9 6� h� DATE: 7/JR l I <br /> PROPERTY I BUSINESS OWNER® OPERATOR I MANAGER IJ 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, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmer�Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time If IS pfgyt�11]�tile or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: r 0 �Ii"a � �U �` T <br /> COMMENTS: <br /> NF�Nt,�AO�yNc ��6 <br /> h�F gNNTq�N <br /> A �t TDENT <br /> ACCEPTED By. ✓l M /l EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: -7 <br /> Date Service Completed (if already completed): SERVICE CODE: VLM12 I PIE <br /> Fee Amount: Payment Date <br /> v / <br /> Payment Type > - Invoice# Check# Kecelveil By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/t7/OB <br /> S <br />