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SAN JOAQVI IN JUNTY ENVIRONMENTAL HEALTH'. 'ARTMENT <br /> SERVICE REQUEST FADDD1219 3 06rrec 7t 9A- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST(r# <br /> OWNER/OPERATf3l�` I'll ronQ"�17 <br /> 1 <br /> 4 <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> 4"--2 . <br /> SITE ADDRESS <br /> S treat Number Direction `t�'�l �Strel�t Neme Ci�i Zip Code <br /> HOME or MAILING ADDRESS (If Differ from ite dress) <br /> Street Number Street Name <br /> CITY // SLYTE ZIP <br /> C(� C � <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 � EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACT R/ SERVICE REQUESTOR <br /> REQUESTOR // <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME--/—/,,,, (/C PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY l / TATE ZIP <br /> BILLING ACKNOWLEDGEMENT:: [, 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, ST and FEDERA la s. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL1CANT 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. RPAYMENT <br /> ECEIVED TYPE OF SERVICE REQUESTED: RECEI tl G® <br /> COMMENTS: 1 � <br /> 3-7 8 AJ Nov 12 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: C <br /> Date Service Completed (if already completed): SERVICE CODE: i�/ P I E. <br /> Fee Amount: Amount Paid -1W2-Check <br /> /sem Z Payment Date <br /> Payment Type Invoice# (Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />