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SAN JOAZr_.,J COUNTY ENVIRONMENTAL HEALTH vEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :A (�2'4 U-3--7S � 00&-3�2 <br /> OWNER/OPERATOR ^ <br /> CHECK IF BILLING ADDRESS <br /> FACILITYNAME / W, f7 t k+r L4NF --Z (p <br /> SITE ADDRESS I�I� 4; 1 t /,In I 0 ^ - :J 01(� <br /> Street Number Direction V t Y t V V Street Name Ci J2i Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) r 1 12 <br /> Street Nu tuber �175treet Name <br /> CITYI�(f/ it ST ZIP &I <br /> Li(/f� v l � <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (a,q 546 -05/0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IBJ C CHECK If BILLING ADDRESS <br /> BUSINESS NAME ���r m I n„�� /✓/IV•r'/!/NOu V l.i�� I PHONE# ExT. <br /> HOME Or MAILING ADDRESS Vn�/, 1//I/I� /NA,� FAX# <br /> CITY 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 FEDERAL laws. <br /> �V,tC�C <br /> APPLICANT'S SIGNATURE: ` 4zGrd� DATE: Or —/0 <br /> PROPERTY/BUSINESS OWNER PERATO MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Iot 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 and/or environmental/site a ssment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time jded to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Vo I / <br /> COMMENTS: 1'� <br /> � 2019 <br /> H *tl✓ N/NCOU <br /> �/O�OF'1fFNT,�'V)Y <br />' '4RlIyFNT <br /> ACCEPTED BY: ` V 4 EMPLOYEE M DATE: <br /> ASSIGNED TO: �A v rEMPLOYEE#: DATE: <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: PIE: O <br /> Fee Amount: I Amount Paid / S 0/—) Payment Date /y'/ I <br /> Payment Type Invoice# Check# Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> l <br />