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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property � +\�F�ILI�D# ��nSER�VIf��QUEST# <br /> uu G' UflJl�d/f� ✓' <br /> OWNER/4P u li s S , CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS ^ ,� `�� ` :779 9 <br /> 1'3Street Number Direction ,V Street Name 'T J" ` Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street N mbrr Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. ApN# LAND USE APPLICATION# <br /> (�3d <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BIL DDRESS <br /> BUSINESS NAME PHONE# Evwl V <br /> HOME or MAILING ADDRESS FAX# JUN( ) /Y <br /> CITY / ,� STATE Zi ENOgQUIN C <br /> -Arm <br /> BILLING ACKNOWTDGF.MENT: I, the undersigned property or business owner, operator or authorUTA ,ppe <br /> acknowledge that all site and/or project specific ENVIRONMENTAL.HEALTH DEPARTMENT hourly charges associated with this prof ct <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 1 S. <br /> APPLICANT'S SIGNATURE: (___;ZI DAI-F:: <br /> PRorrRTY/ *si rss Ower Q� fh> Aron/MANAGER Q fT rrr.R ATTT1TORfZEn AGr!rr❑ <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. <br /> TYPE OF SERVICE REQUESTED: y r <br /> COMMENTS: <br /> L L C�_ dw��� s�:ti Q JUN 11 2020 <br /> It\l")NMENTAL HEALTH <br /> L RI'J!1T/SERVICES <br /> ACCEPTED BY: C EMPLOYEE#: DATE: n 'I �f <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' IPYI <br /> Fee Amount: Amount Pai l/SPayment Date <br /> Payment Type Invoice# Check# 17Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />