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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -F <br /> JWNER/OPERATOR n 1�I ' <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Q� 5-A-04 <br /> 1101 2® Street Number Direction Set Name G Cit Ziode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EST• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT �.— ][LLDCAT�71N ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR w I CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME {� V t+l'�.r PHONE# Exr' <br /> HOME or MAILING ADDRE3 /� A 4 'f C� FAX <br /> `jam f�(,l V 1 ( ) <br /> CITY QG C <br /> STATE ZIP I <br /> BILLING ACKNOWLEDGE ENT: 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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa s, TE and F`DE L a s. <br /> APPLICANT'S SIGNATURE'l' DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ ER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authoriO z ' n 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,yl Sari1C_time it is <br /> provided to me or my representative. 1f'+' T 1MY1Gff4T <br /> 42 , r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 0 5 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTEDBY: ,'- ✓��aICC+�l �cF� �p� EMPLOYEE#: DATE: 2 S Z0LJ <br /> ASSIGNED TO: G 5 s EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J P i E: <br /> Fee Amount: Amount Paid b g— Payment Date `a 5- <br /> Payment Type Invoice# Check# Received By: it <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />