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SAN JOAQUIN G. JNTY ENVIRONMENTAL HEALTH DEPA,..'MENT <br /> SERVICE REQUEST <br /> Type of Business r Property FACILITY ID# SERVICE REQUEST# I <br /> �\ S�Z <br /> OWNER/OPERATOR — `- <br /> cQ1^�( CHECK If BILLING ADDRESS El <br /> IFACILITY NAME I(] `j1 l 1 <br /> SITE ADDRESS <br /> 2 rr``// �� C0s� wu� K�-n �1� 1 SL�s <br /> �L(D � Street NOAber I Direction Y�1�n .Street NIme.4, _ Zi Code I <br /> HOME Or MAII ING ADDRESS (If Differed:from Site Address) <br /> 32) 3 _L_ 3V \\ <br /> ..._._._ Street Numb,-; I_ _ Street Name <br /> CITY STATE ZIP _ <br /> Syc Col Szo J <br /> PHONP#1 EXT. APN# LAND USE APPLICATION# <br /> qoj) e)'+y -43ei l <br /> ^40NE#2 ! ExT• BOS DISTRICT -- LOCAnON CODE <br /> Uc ) 29Z �! 1oc> <br /> (Z` s5�-63 FU- CONTRACTOR/ SERVICE REQS TES's'®R <br /> -EQUES i 1R 1 /� Lr�``` , a CHECK if BILLING ADDRESS <br /> C��, \TA_\_ <br /> BUSINESS NAME �J PHONE# EXT. <br /> Uy \ Cos 0IA'\'(N I��C -9 9 6,1-;Jj <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY cc STATE 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. <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 rFAEDERAL laws. <br /> APPLICANT'S SIGNATURE: Q '(\� V` �G DATE: L6/23 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data ar-d/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provik(l to me or <br /> my representative. `{ �/ Y rtzct, <br /> IT <br /> TYPE OF SERVICE REQUESTED: -C�+o C1 Q I o ) C V e ct- �J N D <br /> COMMENTS: �� � ii 2, 3 <br /> Yt�` Z� <br /> n SANJOQ <br /> V INN <br /> qVVRCMEM Ivry <br /> NT <br /> ACCEPTED BY; n/ EMPL(iYEE#: DATE: _ <br /> ASSIGNED TO: �+mss( — EMPLOYEE#: DATE: <br /> Date Service Comple d (if already complete l): SERVICE CODE: �� PIE: <br /> Fee Amount: p0 Amour ?aid Payment Date <br /> Payment Type Invoice# _ Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />