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V <br /> SAN JOQ�". .OUNTY ENVIRONMENTAL HEAL7,_ APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# . <br /> �o-J-ar m,'L s�-00 16 <br /> PE ATOR <br /> CHECK II BILLING ADDRESS <br /> Ol Wyjgv v <br /> FACILITY NAME <br /> (A., �Y <br /> SITE ADDRESS <br /> 2 Ir Street Number Direction Street Name Cit J 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 /> 961 ) 'H (�3- 12 L.0 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR )q(b Y()'„`�Uv, S �tU A� V Av` <br /> "I CHECK if 1BILLING <br /> �ADDRESS <br /> BUSINESs NAME PHO� EXT. <br /> Z- <br /> HOME or MAILING ADDRESS FAX# <br /> Du <br /> CITY 'J_`1O nV - <br /> y C y ' STATE / ZIP c (' <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, S ATE a d FEDERALFs,,,, <br /> APPLICANT'S SIGNATURE: V( 'all ✓Z— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT❑ O(/�t" <br /> IfAPPLICANT 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 /> 3 AR 3 2020 <br /> V JOAQUIN <br /> y�eCo <br /> TY� AJ1ART <br /> ACCEPTED BY: Cn EMPLOYEE M DATE: <br /> ASSIGNED TO: S, EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O \ <br /> Fee Amount: ,-C)Q Amount Paid Payment Date Olab <br /> Payment Type _ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />