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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �S RVOI���CyJ�}� <br /> OWNE,q/OPERATORv I <br /> 1 I CHECK If BILLING ADDRESS <br /> FACILITY AME `; 06S <br /> SITE ADDRESS_ l/� jI CAQy��) <br /> CDStreet Number Direction ` ` O 1tree ame ` � Zi Codes <br /> HOME or MAILING ADDRESS (If gTerent from.Site Address) <br /> II Street Number Street Name <br /> CITY-5k . CR ��� �— STATE ZIP <br /> L,CPHONE#1 _ EXT* APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �`J` C CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' � �\�^ P p E i ^ EXT. \ <br /> J /l\J M1I 1 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> r �J <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,Slandardy, STATE and FEDERAL la <br /> I i <br /> APPLICANT'S SIGNATURE: ~- DATE; — � � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 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 t1w same time it is <br /> provided to me or my representative. !''SAY <br /> TYPE OF SERVICE REQUESTED: I cel <br /> COMMENTS: p ,IU <br /> v� 0 <br /> Mg3 2020 <br /> EOUNTT <br /> YLTM pEpRE <br /> ACCEPTED BY: Lal A ra EMPLOYEE#: qt'22/J DATE: U 10 <br /> ASSIGNED TO: NA V I EMPLOYEE#: v DATE: l� <br /> Date Service Co pleted (if already completed): SERVICE CODE: t4� P/E: '3 <br /> Fee Amount: Amount Paid '- Payment Date 2 /d/ <br /> Payment Type C l Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />