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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAGILITY la# SERVICE REQUEST# <br /> eqIr n <br /> m �V OFF ALVV_7 <br /> OWNER 1 OPERATOR ' <br /> CNEcK If BILLINGAooREFAcluTr NAMEAw-6.,, <br /> SITE ADDRESS <br /> �� trvet Nurnhar �� a sal NaZ'Y <br /> Home or MAILING ADa7Rkss (If Ditto-rent from Slto Addro s) <br /> Slrevl Number Straal Name <br /> CrTV STATE Zip <br /> PHONE 91 APN# LANO Usti APPLIGATiON M <br /> ( l r <br /> r <br /> PIIUNE 92 Ems• BOS DisTHlcT LOCATION CODE <br /> ( <br /> CONT ACT R t SERVICE REQUESTOR <br /> REQUESTOR <br /> /;/ <br /> n_ CHECIf it BELLIIvGAAQRESS <br /> u'A14 / � _Ib � <br /> BUSINESS NAME � � PH <br /> HOME or MAILING ADD Ax# <br /> ( � <br /> CITY /f STATE zip <br /> BILLING ACKNOWLED E 1ENT: 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 /> 1 also certify that I have prepared this application and that the r to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA I. I ►►s- 1C <br /> APPLICANT'S SIGNATURE: D VTF: ~ a <br /> PROPERTY I BUSINESS OWNER13 OPERA 0RI MANAGE OTHER AtmtORIZED AGENrr❑ I r] <br /> Y'APPLICAYT rs not the BILLING P,tRrY.proof of authorization rip sign Is required Title iel <br /> AUTHORIZATION TO RELEASE INFORMATION; When applicable, 1, the owner or operator of'tlte property located a( the <br /> above site address, hereby authorize the release of any and all results, geotcchnical data and/or envircamcninllsitc 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 REQUESM: T <br /> coMM wrs: nIECEIVED <br /> ' 1 6 2D'9 <br /> :AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> -"1 TIJ. r,~PAIZ TTLI ENT <br /> AccEpTev t3Y: EMPLOYEE M: DATE. 141-74 <br /> AsSIGNEO TO: EMPLOYEE#: DATE. <br /> Date Service Completed ttt already cempietad): SERVICE CODE: P i E: 12 <br /> Fee Amount: eik Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED IVIV2043 <br />