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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property t 1 FACILITY ID# SERVICE REQUEST# <br /> t�l�uS e CZ 03<�' -272 <br /> OWNER/OPERATOR <br /> 0 —TG 0' e\k ay <br /> FACILITY NAME CHECK If BILLING ADDRESS <br /> , Jr `YJ l 1. Y t V <br /> _ SITE ADDRESS r7 <br /> Iq <br /> Street Number I Direction a Z' Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. N# LAND USE APPLICATION# <br /> AP <br /> (2-0 - '7 a 077. 7 n 13 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION//CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 FEDE AL <br /> APPLICANT'S SIGNATURE: DATE: <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, 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: UPr�FII�:�toi� 0`F 60" lecckt 1inE. g1,r6V Sed <br /> COMMENTS: (OWnef WooiC) like -to lnsltrill Pte' bpi ))'Pe 61ocl sut-,p y Cl/ <br /> ureci, owner s4elk-5 rbla-f )jnes he,ve beetn /Vel-/ lice gets pU >t ,r►' ED <br /> permif sRvo$do�1, <br /> g 2020 <br /> cedl Q01) to ce heddif �'ANJOAQUIN COU <br /> NTV <br /> ACCEPTED BY: EMPLOYEE#: DAT �� E <br /> ASSIGNED TO: D EMPLOYEE#: DATE: c1d lr k 0 <br /> Date Service Completed (If already completed): SERVICE CODE: �� ) PIE: LJa J a <br /> Fee Amount: i Sa Amount Paid Payment Date <br /> Payment Type Invoice# Check# Recei ENT <br /> cenEHD 48-02-025 SR FORM(Go a od) <br /> REVISED 11/17/2003 JUN 2 JA �020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONI�dIr,�,� <br />