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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �A I q Ig <br /> OWNER/OPERATOR <br /> A A/—� CHECK If BILLING ADDRESS <br /> FACILITY NAME !/ L `j <br /> SITE ADDRESS S <br /> 7'L! v Street Number Direction Street Name �� �Z Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number U Street Name <br /> CITY STATE ZIP <br /> JL1 <br /> L� � <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 2" — 6.7 ((J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> U � CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` � P��� `�� _ r-Z� EXT. <br /> G' Y1 (/ <br /> HOME or MAILING ADDR SS '] FAX# <br /> Cl CITY 5I ^ " STATE C4, ZIP ',5-2 (Z <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, STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: % > / DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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, 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 availablL� t the same time it is <br /> provided to me or my representative. I� <br /> TYPE OF SERVICE REQUESTED: JJ ' <br /> fvuy <br /> COMMENTS: �JOAQU� 2019 <br /> MFNT <br /> ACCEPTED BY: s EMPLOYEE M 3 DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE:I `7 1 <br /> Date Service Completed (if already completed): SERVICE CODE: 1 E' <br /> Fee Amount: Amount PaidI�� Payment Date <br /> Payment Type �� Invoice# Check# Received B �✓ <br /> EHD 025 f I I SR FORM(Golden Rod) <br /> REVISEDSED 11/17/2003 I f f <br />