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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t J C Cod ld <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> �) <br /> eA <br /> g � r <br /> SITE ADDRESS <br /> Street Number ectlon treat Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3 U a �� Street Number Street Name <br /> CITY � y) STATE ZIP <br /> 4 r 1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# l <br /> (Sim ► " S u - � y _ o a PA 1700\' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 5 V0� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 1 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, T FE RAL laws. <br /> APPLICANT'S SIGNATURE: �X DATE: <br /> --r <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f 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: r414 <br /> COMMENTS: <br /> J RECEIVED <br /> I LIN 0 4 2020 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: �i/VIi' C ti EMPLOYEE#: DAidE� PL���v1ENT <br /> ASSIGNED TO: / J EMPLOYEE#: DATE: 6 U d�U01`j <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 P1 E: a6 Ga <br /> Fee Amount: 3 J L? Amount Paid ( 8 Payment Date Z11ce <br /> �, n <br /> Payment Type Invoice# Check# �7:4t j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />