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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPfWTOR <br /> CHECK if BILLING ADDRESS <br /> ,IDV-qe Vilqeiae <br /> FACILITY NAME <br /> o O <br /> SITE ADDRESS /V NNL�� /�. 9S'2Ll7 . <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SO(/I t e_ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#i EM. APN# LAND USE APPLICATION# <br /> Vpq) 63 - �-2 -:� y <br /> PHONE#Y E2 BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1/t /L <br /> c(� Q CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EM' <br /> HOME Or MAILING ADDRESSAx <br /> ( Oe? / O 77 <br /> CITY STATE e ZIP f 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 TE and FEDERAf;laws. / <br /> APPLICANT'S SLGNATU ©k G ►/�I�G�G7�7� 2 DAT 2 /O `l! 2 -' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ U OTHER AUTHORIZED AGENT❑ ' <br /> IfAPPL1CArT 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 <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: �^` /` A/W <br /> _Ou;�'�''�—Vw'_ Fri pg 2023 <br /> 11— t�lJ SANJOgQU1N <br /> ACCEPTED BY: EMPLOYEE#: to 3 DATE: LQ c'� fi <br /> ASSIGNED TO: EMPLOYEE#: it) q4 DATE: 9 7-3 <br /> Date Service Complete (if already completed): SERVICE CODE: P/ r_ 03 <br /> Fee Amount: C2T(O <br /> Amount Pal 1t�e Payment Date 2 q 23 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />