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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> 2iv(0 <br /> OWNER/OPERATOR <br /> 'R Cal <br /> Q CHECK if BILLING ADDRESS O <br /> e , <br /> FACILITY NAME , <br /> SITEADDRESS <br /> Street Number Dlredion <br /> Ntivie r A�Ite kc <br /> HOME or AILING ADDRESS (If D'fferent from a ddress) l `Z Pd. <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT <br /> LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '7 <br /> CHECK if BILLING ADDREwo <br /> BUSINESS NAME PHONE# / D Exr, <br /> HOME Or MAILING ADDRESS41J i <br /> FAX# 1 <br /> CITY ( ) <br /> STATE Zip <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, EDERAL laws. <br /> APPLICANT'S SIGNATURE- DATE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER..��{ RATOR/MANAGER E3OTHER AUTHORIZED AGENT[3If APPLICANT his not the BILLING PART} 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: G �j QPAYMENT <br /> �` <br /> COMMENTS: REGEIVED <br /> MAY 1 1 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I' 7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: C <br /> Date Service Completed (if already completed): SERVICE CODE: , P 1 E: <br /> Fee Amount: Z- Amount Paid ��2 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />