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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ll <br /> yl I <br /> NER/OPERATO <br /> CHECK If BILLING ADDRESS tn <br /> Tv <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �� SI` ,p4,,, Lj7 7 <br /> C;QU IV1`Y Street Number Direction Street Name Iv fC�it Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY 45n STATE ZIP <br /> PHONE#1 ! ` EXT. APN# LAND USE APPLICATION# <br /> (3cO ) Co)- (113? <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> 01'oj 1 D A b <br /> BUSINESS NAME PHONE EXT <br /> eysc 2e( SIBS 20 1 - G � 3Z <br /> HOME or MAILING ADDR SS FAX# <br /> rw�f ( ) <br /> CITYC I n STA Tjs /] ZIP qS,7c <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 /> 1 also certify that I have prepared this ap is i n and that th PVC111k to a performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards and FEDERA a <br /> ` <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPPL/CANT 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 availablZNK <br /> me time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: vet) <br /> COMMENTS: � ' 2019 <br /> SAN jo'�Qlj <br /> HS-ALT/RDNMEtV-rAL <br /> H OEPARTM�NT <br /> ACCEPTED BY: EMPLOYEE M DATE: / <br /> ASSIGNED TO: ' -6 butL EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P1 I E: / <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type '.� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />