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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 /> fob C J) 2✓Y-- Z C„C "—r)k 2 CHECK If BILLING ADDRESSO <br /> P '1 /L <br /> FACILITY NAME /� C 1 ��`J O v U C -tO�'� CCA <br /> SITE ADDRESS �� I 1 P" <br /> treat Name 9 <br /> Street Number Direction �i;?IS <br /> Code <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 /> (z ) Zai <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) L� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �n <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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:.�j� /� -7 <br /> 'It/1 )1 (D I q GI��L�✓Y� L DATE: nli7c�'{7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: LJ j} �)I j} Co C <br /> COMMENTS: ECEiVED <br /> JUN 0 4 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: `I ZJZ O <br /> ASSIGNED TO: IV4. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j P I E: or J� <br /> Fee Amount: (O Y Amount Paid �O g� Payment Date � 2— <br /> Payment Type Invoice# Check# Received By: ( j <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />