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SAN JOAQUIi, —JUNTY ENVIRONMENTAL HEALTH __. ARTMENT <br /> SERVICE REQUEST <br /> Type o Business or Property FACILITY ID# SERVICE REQUEST# <br /> _ a �e- r I nei 032i -219s <br /> OWNER/OPE"TOR } J <br /> _c/-) / <br /> CHECK if BILLING ADDRESS <br /> FVACCI�Tr N :ICA <br /> SITE ADDRESS ! ,/r LJ a f1 Z0 <br /> n r o i �/// //NQS <br /> ytvo Street Number Direction a I eet Name ��� V Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 13057- Street Number Street Name <br /> CITY_ P � STATE ZIP <br /> NE �� /' <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# �J <br /> PHONE#2 FXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR v <br /> I/'��� CHECK If BILLING ADDRESS <br /> BUSINESS NAME/ ��!� y PHO E ExT <br /> [q S / k,612 <br /> (- 600 <br /> HOME or MAILING ADDRESS r/ FAX# <br /> 3 5 7Z Es meWq MI ( I <br /> CITY C�G,Cb �/� 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, S TE a, d FFDERAi,laws. <br /> I <br /> APPLICANT'S SIGNATURE: DATE: <br /> r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 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. r <br /> TYPE OF SERVICE REQUESTED: JC` �1 �/t��7Y!✓w�`- " 'Y e <br /> evi <br /> COMMENTS: 1AZUy' Z9 VZ® <br /> SAN, 2 2019 <br /> FNV AQVIN <br /> h�CTy p�MENT�N)Y <br /> ACCEPTED BY: yA\ i✓V D EMPLOYEE#: DATE: <br /> ASSIGNED TO: - so ' ` A " EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: DlG„ PIE: �p3 <br /> Fee Amount: 1�2 Amount Paid 152- _ Payment Date 1 I 2— <br /> Payment <br /> Payment Type ( Invoice# Check# Received By: V6 <br /> EHD 48-02-025l �l Q C)I1� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ����9(.1 G� 6.� J r 1 , �(/�G�f <br />