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y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7-5 . S12lm 1,, <br /> OWNER/OPERATOR _ <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ��(f �• (�-�f <br /> SITE ADDRESS Cv� Y �� L!Q / cl�20 <br /> Cit StbetNumber Dirctivn / / <br /> Zi Code <br /> HOME or MAILING ADD ESS (if Different from Site Add reSS) f/Fr <br /> `� <br /> Street Number treat Name <br /> CITY ,, f STATE ZIP <br /> PHONE#1 W ExT• APN# LAND USE APPLICATION# <br /> ( l 5( (� <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEXT <br /> R-0W/ o O PHO E .� <br /> HOME OC MAILING ADDRESSr FAX# <br /> 72 Vt �� <br /> CITY .-�,.-s CA-1 <br /> � Jr )vSTATE 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 /> 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 FED <br /> APPLICANT'S SIGNATURE- DATE: <br /> PROPERTY/BUS1NESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZER AGENT❑ <br /> If APPLICANT is not the BILLiNGPARTY 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 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: <br /> COMMENTS: CE/V <br /> Ep <br /> J4N i Z 2021 <br /> !J Qi tlry CD <br /> " cry Q Ivry <br /> ACCEPTED BY: EMPLOYEE#: DATE: '1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: L <br /> Date Service Complete (if already completed): SERVICE CODE: tp P 1 E: <br /> Fee Amount: 1 "J Lam" Amount Paid �� Payment Date 12,124Payment Type k' Invoice# Check# Recived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />