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SAN JOAQ, COUNTY ENVIRONMENTAL HEAL? EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> \\I-,-O CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ��� � '�C• �- V�� `�.���yL_ � ��\j a� ���7[�� <br /> Street Number Direction l� Street Name co <br /> Cit ` Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) G\— <br /> � S <br /> Street Number Street Name <br /> CITY ';��(�GY STATE ZIP 1—�� <br /> PHONE#1 \\J EXT. APN# C•LAANDD`USE APPLICATION# C/\_J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR \�O � CHECK if BILLING ADDRESS O <br /> Yl 2 c� <br /> BUSINESS NAMEPHONE# EXT. <br /> 'p'Gk9aS (-2 q <br /> HOME Or MAILING ADDRESS �\� � � FAX# ) <br /> CITY STATE Q70r 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 FEDERAL laws. <br /> UAPPLICANT'S SIGNATURE: �/ y;/�to �1�,(/���u DATE: " 2'Zd <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPPLICANT 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: <br /> COMMENTS: <br /> 2 2020 <br /> 1RONMOV7, 1' <br /> MD®�pM�NT <br /> ACCEPTED BY: C� �(� (3\( <br /> J�( \(-\6 'L EMPLOYEE#: DATE: <br /> f� <br /> ASSIGNED TO: .n\JR. 60 EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: \U p2 <br /> Fee Amount: ��/l, Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />