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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of usines;a or Property FACILITY ID# SERVICE REQUEST# <br /> � � I4z ���� 117 3 <br /> OWNER/OPERATOR _ <br /> 6��'n+ 1 CHECK if BILLING ADDRESS E] <br /> ✓ lx 7 <br /> FACILITY NAME <br /> SITE A�DD{RISS i`,�`ey` ` <br /> 91,: Street Number Dfr�ction treet Na e Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from,Site Address) <br /> Ct7 Ivy Street Number Stre�et(Name <br /> CITY STATE ZIP <br /> v A <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) o,t,3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION D <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS 14AME (� PHONE# <br /> HOME or MAILING ADDRESS FAX# ' <br /> /LCc Zr LJB <br /> CITY STATE zip <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,S TE and FEDE aws. <br /> APPLICANT'S SIGNATURE' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE OTHER AUTHORIZED AGENT IJ <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. P <br /> TYPE OF SERVICE REQUESTED: � � RECEIVE <br /> COMMENTS: CIZ �1/z_/ Z044 16"-1 SEP 18 2019 <br /> /'/ /� SAN JOAQUIN COUN <br /> IY <br /> ENVIRONMENTAL <br /> l R ©� HEALTH DEPARTMENT <br /> ACCEPTED BY: { CJ EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q/ P I E: 2 <br /> Fee Amount: �Z� Amount Paid } S'Z — Pa rent Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />