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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/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 6A-iiv`` �\ c �p <br /> SITE ADDRESS CUC�y"VY `1 N <br /> 1 Street Number I DirectionStreet Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> OL�'O `IF)'l- 51 (�,'�, <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> NE# ExT' <br /> BUSINESS NAME PHO <br /> 09 cl , (j 1110 <br /> HOME or MAILING ADDRESS FAX# <br /> G <br /> CITY / N-b C� ; STATE CA ZIP CI5 2 l <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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNAT E: DATE: 2 21 2`' <br /> PROPERTY/BUSINESS OWNER b----1/OPERATOR`/MANAGER 10 OTHER AUTHORIZED AGENT❑ <br /> /f 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 envi nmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabli me time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: ' f'C �✓� �� 0^C J mow., 2020 <br /> MS �EP �NT-r TYNMAMENT <br /> ACCEPTED BY: lEMPLOYEE#: l l Q DATE: 2j <br /> ASSIGNED TO: Ir' Q EMPLOYEE#: / v DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E.1 <br /> Fee Amout. Q Amount Paid (�a�� Payment Date �4 1320 <br /> Payment Type C) Invoice# Check# Received By: <br /> EHD G� U—M SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11/17/2003 <br />