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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID #� RVICE REQUEST # <br /> q S(A) 0/ Vh <br /> 0(VV00q <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS ❑ <br /> r,. , (kLlU i` iZ� A) Pt 1 I _L U <br /> FACILITY NAME <br /> SI THo <br /> SITE ADDRESS (� /1 <br /> I 'let Street Number Dir-d ion Street <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 /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR i 1 <br /> 2 � T 1T 0 4� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT' <br /> HOME or MAILING ADDRESS FAX # <br /> CITYl , �y 5 S� TE ZIP <br /> fn tO � <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 /> APPLICANT ' S SIGNATURE : ►— �— DATE : <br /> PROPERTY / BUSINESS OWNER ❑ 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It 'is provided to me or <br /> my representative . PAYMENT <br /> TYPE OF SERVICE REQUESTED : r , (� � � .V1� RECEIVED <br /> COMMENTS : SES' 16 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : Y Ct EMPLOYEE # : fl <br /> DATE : I 2 Q <br /> ASSIGNED TO : i `, C C� EMPLOYEE # : ! n �' DATE : C I WI /7 I /7 <br /> Date Service Completed (if already completed) : SERVICE CODE: cl PIE : 2309 <br /> Fee Amount: U G Amount Paid SZ Payment Date ! Y <br /> Payment Type Invoice # Check # Received By: Au <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />