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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A NtP�0O l0 <br /> OWyER/OPE RAT ` <br /> CHECK If BILLING ADDRESS <br /> FACIL N E, <br /> G� 5 <br /> SITE ADDRESS <br /> i�q0 irget Number i e 1 / i tree a e " v �� I <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE l ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) 001 (7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU STOR <br /> i' / CHECK If BILLING ADDRESS <br /> �j <br /> Busl s NAM / P,I+Q ExT. <br /> HOME Or M (LING AD RES # <br /> t. <br /> CITYsrb k. 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: �C <br /> COMMENTS: �� � cc t/1!,�6x � �,D � .S ' 2020 <br /> H&N N COUN <br /> T hQA MENT <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already mpieted): SERVICE CODE: O / PIE' `, C) <br /> Fee Amount: 'ffi 'S Z_ Amount Paid -r; ; , Payment Date ( �p Zo <br /> Payment Type Invoice# Check# .=' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />