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SAN JOAQUIN C NTY ENVIRONMENTAL IEALTH DEPARTMENT <br /> SERVICE REQUES"P 1 <br /> Typb of Business or Property FACILITY ID# SERVICE REQUEST# <br /> y�5 <br /> OWNER/OPERATOR // <br /> /�/�'IC ,� uGr CHECK If BILLING ADORESS <br /> FACILITY NAME <br /> SITE ADDRESS /,411g00 <br /> Street Number Direction Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 12/1 - Z <br /> C Street Number Street Name <br /> CITY �ODC. STATE 6,r ZIP S�'S <br /> PHO #1 r APN# LAND USB APP- TION# <br /> ( �, 238-3666 ozi-oso-i� .� <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> 'pi /�-Iur `j 109 33'f -66/3 <br /> HOME Or MAILING ADDRESS �j0 /-3OX -2100 F(,20f) D723 <br /> CITY L��� STATE /'A ZIP ) --21 <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,STATE and DERAL I s. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> /,O/ <br /> PROPERTY/BUST\ESS OWNER❑ OPT R/MAN ❑ THER AUTHORIZED AGENT <br /> IfAPPL/CANT is not the BJL!L GPARTY p oofof 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 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: OroaGG �JU�S✓�>�C� r'4`(MV'N� <br /> COMMENrs: <br /> 10 <br /> QUIN COUNTY <br /> SAN JOA <br /> ENVIPONMENTAL <br /> Q <br /> FO�J J HEN-TH pEPARTMENT <br /> O <br /> APPROVED BY: 0 W%-�t Lf/� EMPLOYEE#: 24 DATE: IO Lr O <br /> ASSIGNED TO: � iN EMPLOYEE#: DATE: /U 2� C`J <br /> Date Service Completed (if already completed): SERVICE CODE: 3 /S PIE: <br /> .R3 <br /> Fee Amount: D� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 65-02 <br />