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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type usiness or Property I FACILITY ID# SERVICE REQUEST# <br /> -� /,J-,5;"z0'h--ck / ; ` .�— <br /> OWNER/ PERATO / <br /> 2 /� CHECK If BILLING ADDRESS <br /> erl ff/(-f <br /> FACILITY NAME (((///��� <br /> SITE ADDRESS <br /> eet Number Direction / t Zi Code <br /> H Or MAILING ADDRESS Different from Site Address) <br /> Street Number '1/ �' YU/ Strelet Name <br /> CITY STA T ZIZZU <br /> C g.� <br /> PHONE#1 EXT APN# LAND USE APPLICATION# / <br /> vi7 .2yv"v� VO <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO 0. <br /> ( ) sq 11 2019 <br /> "WuCONTRACTOR / SERVICE REQUESTOR PcS*IIRoNME outoy <br /> REQUESTOR � <br /> CHECK if BILLING ADDRESS <br /> IT <br /> BUSINESS AME PHONE# <br /> HOME or MAILING ADDRESS —go FAX# <br /> CITY STAT ZIP —7 S� <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that ail 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 FEDER <br /> APPLICANT'S SIGNATURE- '� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGE OTHER AUTHORIZED AGENT <br /> /f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br /> TYPE OF SERVICE REQUESTED: CG- <br /> COMMENTS: VCOMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: V1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid UL Payment Date <br /> Payment Type Invoice# Check# U Received By: y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />