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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' �� 1 � ©4, SR oovQus <br /> J.— 10 1,1 r),� a(�OWNER/0414ATbIR <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS / �� � �d� Q cel '/ <br /> Street um er Direction treet'Jame Cit i Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) %1 C 'T <br /> C 2 Z— d Street Number Street Name <br /> CITYf � STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 2Q�) <br /> PHONE#2 ` EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR M n7�{,MT n,ry -66/ <br /> l� CHECK If BILLING ADDRESS <br /> BUSINESS NAME y ^/ PHONE# EXT. <br /> A" Ap,HOME or MAILING ADDRESS FAX# <br /> CITY STATE LA C 14ZIP <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 t e wo k to e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERA ,aws <br /> APPLICANT'S SIGNATURE: DATE: — <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER I ` OTHER AUTHORIZED AGENT❑ <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: �c,U �,v—��� PA <br /> COMMENTS: <br /> JAN 2 2 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HENCTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> l—2Z—20 <br /> ASSIGNED TO: Ga LAvV EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ©� \P 1 E: j b02, <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �'P�Jul z-13 \�. <br />