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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Q�c-V/ Sk 0 0� IV6- <br /> OWNER/ PERATO <br /> L VL CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS / J✓JC �tpE7 �f <br /> d � Street Number Direction treat Name Ci ode <br /> HOME or nMAILING ADDRESS (If Different from Site Address) <br /> Com" U Street Number Street Name <br /> CITY / STATE ZIP <br /> Gat -a, �" -: �•3^2lJ7 - �? <br /> PHONE 91 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUE$TOR <br /> CHECK If BILLING ADDRESS <br /> 412, <br /> BUSINESS N,4ME lJ PHONE# ExT. <br /> AbLl > vaGS (,o Z`(o <br /> HOME Or MAILING PDRESS FAX# <br /> CITY STATE /'^ ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: /LZ y� L� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/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 available and atie time it is <br /> provided to me or my representative. ! -- rM� <br /> TYPE OF SERVICE REQUESTED: (M1 � ti /VE <br /> COMMENTS: �� ��i�� � l S la-'w` 'a JAN O" 2020 <br /> 1 V S tR�1JiN COON1 Y <br /> h Tk io L MEN <br /> ACCEPTED BY: EMPLOYEE#: D C DATE: / Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S I E: - <br /> Fee Amount: 3 L' Amount Paid Payment Date �ZD <br /> Payment Type l Invoice# Check#, Received By: <br /> EHD 48-02-025 1 �+ ✓ V SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />