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SAN JOAQUIN COUNTY ENVI RONMENT4L HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> llca�� ��C>O , c c' <br /> OWNER I OPERATOR�y Al/`"( CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �Q DS.,.S� E, U.t/D•�-�Pwo0O �y'S Sap <br /> Street Number Direction Street Name City/i4 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t i '' APN# LAND USE TION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR ZL CHECK if BILLING ADDRESS <br /> BUSINESS NAME PH2 C Sj�J--/ 5'Z 1 <br /> HOME Or MAILING ADDRESS Zf Z/ t V Q�,r�� Z- (-10^ 3//3��4.(!_J <br /> CITY O 61/ L `/�/ (� STATE l" t//) ZIP <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 ,.j <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 /> APPLICANT'S SIGNATURE: DATE.::( /Z - ZO^D 5 <br /> ❑ <br /> PROPERTY/BUSINESS OWNERT PERATOR/MANAGER 110TTIER AUTHORIZEDAGENTYSI <br /> 1fA,PPL1CAArT is not the BiLL/NG PARTY proof of authorization to sign is required U 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 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: SU t CC JVf�SV P C_�Y17?i f Nq I�bfif <br /> COMMENTS: I `/a'.� ._. �j/((/�j� D^ <br /> 4 'N.^i^ C'/ - ggry�C 2 22005 <br /> �h Oq <br /> 0//V C00117 <br /> ACCEPTED BY: EMPLOYEEM 't'o DATE: 2 y� <br /> ASSIGNED TO: <br /> EMPLOYEE / DATE: �7 22 —] <br /> Date Service Completed (if already completed): SERVICE CODE: �j� P I E. <br /> Fee Amount: Amount Paid -00 Payment Date \2 Z�- QS <br /> Payment Type ✓ Invoice# Check# t- Received By: <br />