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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Hoo I -Dm-iICf -tT 6610450 sqm&w& )2 <br /> OWNER I OPERATOR <br /> 11 <br /> I ,�� `_'-�, ` <br /> FACILITY NAME CHECK If BILLING ADDRESS <br /> � U ��JCJ I 1(/ <br /> 1 Q S U <br /> SITE ADDRESS 202o ►A \ �r 0 i stock:+V' 1915207 <br /> Street Num'-' Direction UUCA Stroet Name v Cit ZID Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number7 Street Name <br /> CITY STATE ZIP <br /> PHONE#t ExT- APN# LAND USE APPLICATION# <br /> PHONE#Z ExT• Ir BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C r+� CHECK If BILLING ADDRESS <br /> BUSINESS NAME t G i l C U hi l,C �W 1 !�S kF7 <br /> 9 _e � Exr. <br /> O. E Or MAILING A DRESS l nl Ci ��/�t-"I f' -e/ 17_ �`��D <br /> CITYSTATE ZIP 9526-J' <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: DATE: <br /> PROPERTY/BUSINESS OWNEIZ❑ OPE ATOR i IVIANAGFR ❑ OTtIF.R AUTHORIZED AGENT <br /> If APPLICIA'T is uol the BILLING PARTY,proof of autharitation to sign is require 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 cnvironmental/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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ge.'g- <br /> -�+`/� �AI—f��V -`�1 ` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE q <br /> eV r DATE: .,[ <br /> ASSIGNED TO: EMPLOYEE#: DATE: ( r:�L-3 <br /> Date Service Complet (if already completed): SERVICE CODE: (0 P 1 E: D <br /> Fee Amount: t Amount Paid / Payment Date <br /> Payment Type '112111 Invoice# <br /> Ch <br /> - <br /> Payment eck# Receive By: <br />