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SAN.TOAQUORCOUNTY ENVIRONMENTAL HEALTt- DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII ITY ID# � n <br /> SE�ICE�QUEST# <br /> " 1 1 <br /> OWN R/OPERATOR <br /> Y- <br /> % /A ZZ& -es <br /> HECK if BILLING ADDRESS <br /> FACILITY NA <br /> C-11 Or x- <br /> SITE ADDRESS / <br /> 1 Street Number Dreectio <br /> t" J U� S treat Name Cit Zi Code <br /> HOME Or MAILING/ADDRESS (If DifferentfromSite Address) <br /> (' /(U/7 q L✓I Street Number Street Name <br /> CITY STATE ZIP <br /> h-,- & - <br /> PHONE#'I ExT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (20 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 67 CHECK If BILLING ADDRESS <br /> BUSINESS NAME V r r/ J / PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY SITAT� 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 /> 1 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, ATE nd FEDERAL law <br /> APPLICANT'S SIGNATURE: '�� DATE:��I����!/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA R 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 salve time it is <br /> provided to me or my representative. Q IQ <br /> TYPE OF SERVICE REQUESTED: I PAYMENT <br /> A <br /> COMMENTS: I RECEIVED <br /> at,eA tb L 8 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEP TME T <br /> ACCEPTED BY: r�jJ 1^ EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 v 1 l n� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P A: 7 <br /> Fee Amount* Amount PaidwJ u� Payment Date / 12 4? 2 <br /> Payment Type Invoice# Check# Received By: l ^tJ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />