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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII ID# SERE EQUEST# <br /> (�L ��� ugy� <br /> OWNER/OPERATOR <br /> G� r✓ `AA `��� Z CHECK If BILLING ADDRESS❑ <br /> 14 <br /> FACILITY NAME !'�( <br /> SITE ADDRESS 'n <br /> .Z '�o Sheet NumberDirecti7t'Gt/ tinetG� Y <br /> ZAo Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5670(i <br /> Sttrreet Number Street Name <br /> CITY STAZIP <br /> CA C1 Z/ <br /> PHONE#1 ET. APN# LAND USE APPLICATION# <br /> [9eA I LA-1 1- 60� 1 <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQY-ESTOR <br /> REQUESTOR <br /> . � � G✓ /i A��� ���� ( 2 CHECK If BILLING ADDRESS <br /> BUSINESS NAME Yl�l NX PHONE# EST, <br /> C All Vy" <br /> HOME or MAILING ADDRESS FAX# <br /> Oo � . L e lag- ( ) <br /> CITY STATE CA Zip / S Z/Z <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 /> 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:i � DATE: 0 rl .OLS <br /> PROPERTY/BUSINESS OWNS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJAPPLICANT 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 14EALTH DEPARTMENT as soon as it is available and at the same time it Is <br /> provided to me or my representative. '` p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> AUG 2 0 2�0 <br /> �T tR NMF Qt''+'7'r <br /> H DfPgRT/Nct. <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: IAS I EMPLOYEE M 32 DATE: <br /> Date Service Cgmpleted (if already completed): SERVICE CODE: 0 P E: <br /> Fee Amount: ZQv Amount Pair /s�,U� Payment Date �Z C? <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />