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SAN JOAQu,N COUNTY ENVIRONMENTAL HEAL'. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I OWNER/OPERATOR <br /> f�66 E)Ula-, V Z)/`�, /o' CHECK if BILLING ADDRESS O <br /> FACILITY NAME , �--(J�� D <br /> SITE ADDRESS y <br /> l <br /> StreetNumber Direction �r7 CIC �4 3 <br /> treet Name <br /> city Zi Code <br /> Hor4E of MAILING ADDRESS Of Different from Site Address) <br /> � j <br /> C L l Z ti—lA e <br /> Street Number � � treet Name � y <br /> CITY ����1,���-,� STATE (J ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I-2-'� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> J <br /> BUSINESS NAME L M J^"�� �7 PH�E# EXT. <br /> � 6,O/ _ 9 L J <br /> HOME or MAILING ADDRESS r l �L FAX# <br /> CITY S`�fc�' STATE ZIP C�/ <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: — —Zu <br /> PROPERTY/BUSINESS OWNER❑ BATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPPL/CANT 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: i;;�OUA <br /> PA <br /> COMMENTS: <br /> FCE/VEb <br /> @AN,I q� 1 0 2020 <br /> ENylROU/N COUNTY <br /> H4AC NMENr ]Y <br /> ACCEPTED BY: �� �1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ L'LJ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q U\ PIE: �L <br /> Fee Amount: � Z Amount Paid i __ Payment Date 3 6 � <br /> Payment e � 'Invoice# Check# Received B <br /> Y YP ii , t' c, Y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />