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.Y I��S g nee )'s CSCE L CI - <br /> SAN JOAQ .4 COUNTY ENVIRONMENTAL HEA. _i DEPARTMENT <br /> SERVICE REQUEST <br /> 'ype of Business o6p Property _ FAC;'!TY!D# SERVICE REQUEST# <br /> OWNE /OPERATOR <br /> CHECK If BILLING ADDRESSE] <br /> FACILITY NAME M O <br /> SITE ADDRESS 13 I /D0. C v 4 Sr k70-A) I S•2o � <br /> Street Number Direction Street Name Cit ZIo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ex7. BOS DISTRICT LOCATION CODE <br /> deli 1 <br /> �sz79 9 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C /� /•' O (� I e CHECK If BILLING ADDRESS <br /> BUSINESS NAM �GGLL (J h r PHONE# Eur. <br /> HOME or MAILING ADDRESS FAX# <br /> ' CITY `_ 1 �'Y�l_��.L__ STATE -- ZIP �'/y�?G9^!u�•�'._...-.._.. <br /> f BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> i <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 <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, <br /> -- ':`.i3f' i1TY i l tf+4±�FJ� �iVyEll l Standards, ST anDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: 12- <br /> 0 <br /> Z <br /> �TR A1TFfI217D <C�:R,.i , N1A.,,%cFA 1 <br /> - <br /> If APPLICANT is notl�t''e BILLING PARTY,proof of 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 data4,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: ( e v .f cL s 2 AJ S e N S ]Jo (3 a / a >✓c e 3 ►— <br /> a COMMENTS: N e Y_ o cf '� e, .� 1 , a( y�� ct e. 1-0 <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: A/E:230 <br /> Fee Amount: T Amount Paid 1� M Payment Date 1 S t S <br /> Payment Type .✓ Invoice# Check# ` O L1 ''l Received By: N <br /> EHD 48-01-025 SERVICE REQUEST FORM <br />