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P 90,5617 `?v <br />SAN JOAQUIN COUN' : ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />V 0 <br />OWNER / OPERATOR KA `; A WMOLVI <br />` <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME ?40. Q%# <br />vc-al Cue� <br />SITE ADDRESS22 <br />Street Number Direction , 1 Street Name • <br />��aci� <br />Z 19561(o <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />P1IONE#1 EXT. <br />-Rol) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORa <br />j <br />190aj�� <br />CHECK If BILLING ADDRESS <br />'knvlo, <br />BUSINESS NAMEP <br />NE EXT. <br />Mir -y0`10 ditimW <br />All/ r / <br />xy <br />HOME or MAILING ADDRES <br />FAX# <br />CITY �nCM <br />STATE W64 ZIP Q <br />BILLING ACKNOWfEDGEMENT: I, the undersigned zrty or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONME It AL 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, S E and F ERAL ws. Q <br />APPLICANT'S SIGNATURE: DATE: v" <br />JJF <br />PROPERTY / BUSINESS OWNER❑ OPERAVR / IVIA AGER ❑ OTHER AUTHORIZED AGENT Ma1„Q�K✓ <br />If APPLICANT 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:CO RE <br />COMMENTS: S�P <br />.SAN 2021 <br />JOAQUIN co <br />HEALTH H AR NrY <br />r <br />ACCEPTED BY: 6 vt <br />L4 EMPLOYEE #: n DATE: 9 <br />ASSIGNED TO: EMPLOYEE #: 9 3 4 DATE: j J <br />Date Service Completed (If already completed): SERVICE CODE: O PIE: <br />Fee Amount: Amount /5.,? - v D Payment Date q <br />Payment Type Invoice # Check #! � 3 eceive By: <br />CoNF• " 1314,33 863 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />