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SAN JOAQUIN COUN'I'Y'LNYWONMUWAL HL <br /> DLI'AITI'NIIsN'#' <br /> SERVICE REQUEST <br /> Type of Business or Properly <br /> FACILITY ID q SERVICE REQUEST If <br /> OWNER/ OPERATOR ^ CHECK It BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS C) I ✓ I`f''� <br /> eel Nmber Direct du Street Nlme "��^J C�t }}(11 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> - Strccl Number Ircci Narne <br /> CITY <br /> STATE� ZIP /7 � <br /> ®p I `� <br /> PHONE KI <br /> EXT. APN q PLANDDAPP (CATION N <br /> C,1�q ) 3 3 L[—,5-9 iPHONE112 Ear. ICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTORV- CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' ® �C PHONE# ` a � EXT. <br /> HOME or MAILING ADDRESS /� FA%A <br /> CITY iJ STATE ZIP <br /> BILLING ACKNOWLGDGIsMrNT: 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 projector <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared (his applicatio l l the work to be performed will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance.Codes,Standards,ST nd FEDERAL la _ <br /> APPLICANT'S SIGNATURE' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIER AUTIIOHI'LEU AGLNTO <br /> IfAPPGCANT lS not the UIU/NG PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RE1,13ASE INFORMATION: When applicable, 1, 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 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: I jyLAT' - Len)w& �grzlg <br /> lyCOMMENT : <br /> 13 <br /> 8 a•►9 lYAnd - C� <br /> � � � slf� / �N RECEIVED <br /> JAN - 6 ffl.: 1=,�a � <br /> (� C) 'INCOUNTYy 1,4ID kC.N.d 1� <br /> �� iiiI I � <br /> APPROVED EMPLOYEE Y: , i JJIP!l�lo DR.' D O <br /> ASSIGNED TO: V EMPLOYEE II: / DATE: V p <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: S-_- Amount Paid J� _ Payment Date I V <br /> Payment Type ✓ Invoice N Check Na 3 Received Ely: <br /> EHD 4"1-025 SERVICE REQUEST FORM <br /> REVISED 6S.D2 <br />