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SAN JOAQf"COUNTY ENVIRONMENTAL HEAI"`I DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME [ , /, <br /> SITE ADDRES a�'I-1 y (;, I 1�n,_ '/��i�/_��)�. Ccs�_ <br /> 20�- Street Number Direction L� L.l�'\ rcetN ��Vv i ZI CoCe� <br /> HOME or MAILING ADDRESS (If Different from Site Address) �v 3 07 <br /> Street Number I''P O /� Street Name <br /> CITY STATE �lP <br /> (f22-7 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> IZO`I ) -75 - 33.22 q-1,?6 - N aD <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( - o <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> / CHECK If BILLING ADORESSO <br /> BUSINESS NAME PHONE# Ear <br /> — _/ <br /> HOME or MAILING AD RESS FAu# <br /> ! p,tQp la #/ ( !!o ) 792-0008 <br /> CITY .1 ,�dk $Tg1EA ZIP '?207r <br /> BILLING ACICNOWI,EDGEMENT: I, the undersigned property or business owner, operator or authorizedagent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HGALTH 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 1OAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL[laws�_�___ I <br /> APPLICANT'S SIGNATURE: DATE: -72-3� <br /> PROPFRTY/BUSINESSOwNER❑ OPERATOR/MANAG Ell ❑ OTHER AUTHoatzEn AOFNT Su/✓�ry{�r <br /> IfAPPLICANT is not the BILL/NG PAR prooJoJaatfuorization to sign is required V Title <br /> AUTHORI7.ATION 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 ENVIRONMEN'rAL HEALTH DEPARTMENT as soon as it is available and at u e same time it is <br /> provided to me or my representative. I EN <br /> TYPE OF SERVICE REQUESTED: 5011 S I RE <br /> COMMENTS: �' D� // /OJ /�//U� \►\l �j t7 <br /> v1plUBjI0OH N HEPI�NNE S10N <br /> ENVIRON' <br /> NV <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNEOTO: EMPLOYEE#: /„ DATE: <br /> Date Servic Completed (if already completed): SERVICE CODE: T'a P I E: <br /> Fee Amount: c2 Amount Paid L -7_ Payment Date <br /> -4 17L o <br /> Payment Type Invoice# Cheek# —7 Received By: 6 <br /> i . <br /> EHD 48-01-025 L-L �. /I_e_S SERVICE REQUEST f� <br /> RFVISFD6>-5-02 C1 T` - 11+ <br />