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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 /> J CHECK If BILLING ADDRESS El <br /> x, xel <br /> FACILITY NAME <br /> SITE ADDRESS `�Jr h <br /> —7 7 J <br /> L J�� Street Number Direction re /Ci 1 Zi Code <br /> HOME or MAILING DDRESS (If Different from Site Address) <br /> Z 8 ()E' <br /> Street Number Street Name <br /> CITY1 STATE ZIP <br /> AC' L <br /> ) <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ON, ) flip, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> LZ)/�' Lk-7111f CHECK if BILLING ADDRESS <br /> i062 NaBUSINESS NAME PHONE# EXT. <br /> Lacas El &2&Z:'a <br /> HOME or MAILINg ADDRESS FAX# <br /> CITY (� l STATE ZIP <br /> K , L� <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 l 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 TATE an 'FERE AL ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERLCL 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: AVO <br /> COMMENTS: E^ <br /> MA y 13 2020 <br /> H L 0IV&f COVN1y <br /> EALTH pEPg N r'AL <br /> ACCEPTED BY: EMPLOYEE#: DATE: '5—' _ 2v <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: I 3 <br /> Fee Amount: J'2 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 /> 0�1(22 ALA <br />