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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i 10ERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> U � <br /> ITE ADDRESS <br /> Street Number Direction \ treet Name �Y\Ci —`z' ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY-- STATE ZIP <br /> �Y \ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR - <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOM Or MAILING ADD SS FAX# <br /> CITY LoxAI�c\yy, <br /> _ STATE C-A ZIP Q <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE and FEDERAL laws. \ (� <br /> APPLICANT'S SIGNATURE: DATE: C)-5?)A T/2—O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIIORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tide <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: Conc'ulta-�ion <br /> p <br /> COMMENTS: RECEIVE® <br /> MAS' 0 4 2020 <br /> SAN JOAQRW ROt4Co <br /> UNTy <br /> AL <br /> ACCEPTED BY: S +(w a h 1'� EMPLOYEE#: DATE: _ tt _ N <br /> L <br /> ASSIGNED TO: F a h ry-1 Y EMPLOYEE#: DATE: <br /> Date Service Completed (if already ompleted): SERVICE CODE: ��; ' P I E: <br /> Fee Amount: Amount Paid I 1EjFa — Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ! I ��nSR FORM(Golden Rod) <br /> REVISED 11/17/2003 ll lJ� <br /> P�-oSa�53� <br />