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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> O5AVY) ��s ,r� CHECK 1f BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS YC GHEP—tLtE L-�t/ -� or olSZ4,O <br /> 9 1 O Street Number Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> s ill Y�/1� IIC oy St-I f p CHECK If BILLING ADDRESS <br /> BUSINESS NAMEy'nn ^^0� •� � (� g PHONE# EXT. <br /> KWi{ffY1�1 �.� t✓ 2-0 �1L'It� 1 <br /> HOME or MAILING ADDRESS FAx# <br /> d CHL:SFNUk" ST ( ) <br /> CITY LLOC STATE ZIP Gi.S'LL( <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 app Iication and that the work to be performed will be done in accordance with all SAN JOAQuIN <br /> COUNTY Ordinance Codes,Standards, S ATE and VSPERAL laws. ` <br /> APPLICANT'S SIGNATURE: Q-ALth t' Q.VtW` DATE: �3 I C2- 020 <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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: IAYNj <br /> COMMENTS: ,`I VEA <br /> MAR a 1 2020 <br /> WRQU1N COUNTr <br /> HEALTH 0 N'EIV <br /> ACCEPTED BY: C- EMPLOYEE#: DATE: <br /> ASSIGNED TO: Cl— , o ��e� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: \�U <br /> Fee Amount: �� IJ � � Amount Paid Payment Date <br /> w <br /> Payment Type Invoice# Check# Received By: <br /> EHD E l o/�I j� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />