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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E-afAu t #6 �� �� l3S )�J- Q <br /> OWNER/OPERA;n dof-re'_ CHECK If BILLING ADDRESS❑ <br /> cJ r 1�,0,IC_ s_ - <br /> FACILITY NAME <br /> rbu <br /> SITE ADDRESS �e/„ I / <br /> Street Number nirection Street Name City Zio Code <br /> HOME or MAILING ADDRESS (If Different from $Rye Address) H� SO <br /> -A <br /> V <br /> t Street Number Street Name <br /> CITY te— STATE <br /> 44 ZI ^ <br /> PHONE#t EXT AP N# LAND USE APPLICATION# s <br /> (Z > ► - <br /> ( r15- I 119-69L- 610 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTORA NG AD <br /> CHECK If BILLIDRES <br /> K <br /> BUSINESS NAME r FFAx <br /> H E# EXT, <br /> 4 S,S/1jGn �Ct►�n.n f.3OG/�{�.S' �� Jr' <br /> HOME Or MAILING DDRESS II # <br /> CITY STATE 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 /> 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,STATE and FE A law n <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 0THrRAUTI4ORIZEDAGENTX'Prd1W& W` <br /> /fAPPLICRNT is not the 1311.1,ING PARTY,proof of authorization to sign is required ritie fJ� <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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PrL) 18 2020 <br /> -rCAy 1 b r G 9 P°'n, �r� SAN ENVIRCINW COUNTY <br /> HEALTH pEMENTAL <br /> ACCEPTED BY: 0.tfez&<5 C O EMPLOYEE#: DATE: D <br /> ASSIGNED TO: P) � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: L P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 /I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 PULL" Arm � � (�`,�— <br />