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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �ooid X200 32 as <br /> OWNER 10 RATOR CHECK If BILLING ADDRESS 13 <br /> ( 6-70- iva ki <br /> FACILITY NAME <br /> Gt (� <br /> 'Sao <br /> SITE ADDRESS /2 j C `� rJ %►S.�LS <br /> `Street Number Direction c� Street Name C Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) c3 as rrl b u.'A ✓e <br /> Street Number street Name <br /> CITY 0 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS //nn,. FAX# <br /> CITYakd,�r ST TE ZIP 9$73 <br /> o I <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 applic 'on a the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E E L laws. /1 <br /> APPLICANT'S SIGNATURE: DATE: //,S'D.6—,-9D <br /> PROPERTI"/B4S1\ESS OR'NE OPE T R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLIA'G 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 environmen al/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at h 11/MiIIle it is <br /> provided to me or my representative.,E, ('o-v4 <br /> �� yy���E1V r� <br /> TYPE OF SERVICE REQUESTED ��� 'o-v4 S '�j I) <br /> COMMENTS: MA I <br /> 2020 <br /> SAN JOAQUIN <br /> HEgLTHC)EpAR T 41S�T <br /> T <br /> ACCEPTED BY: 61 t/r� (S Cr EMPLOYEE#: DATE: j- - 7— ?_,C <br /> ASSIGNED TO: �Tlr I/t(," EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E: 1&03 <br /> Fee Amount: f v� Amount Pai ��a 0D Payment Date1 S <br /> Payment Type Invoice# Check# IOVS 77/ I Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />