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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 /> CHECK if BILLING ADDRESS <br /> V <br /> FACILITY NAME��C,/ <br /> SITE ADDRESS <br /> 6 I U I"�''9C�e ber �{Sirection D�r'�'T�' tteef aN me �/ Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> F' 'O' S Street Number Street Name <br /> CITY STATE C`a- ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (10 ) 1 2-5-3 26 A-,- <br /> Fp(� <br /> ONE#2 EXT. BOS DISTRIX LOCATION CODE <br /> ) f t/a-f <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 /> 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 law . <br /> P YMENT <br /> APPLICANT'S SIGNATURE: �� •/ ' DATE: ED <br /> PROPERTY/BUSINESS OWNERP, OPERATOR/MANAGER ElOTHER AUTHORIZED AGENT❑ / <br /> If APPLICANT is n the BILLING PARTY proof of authorization to sign is required Title a;ir; 0 3 2020 <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the proper ���t at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental si�� L <br /> TAL <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thE18MV4{[GLIPAOMENT <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED: ITr Ml Q <br /> COMMENTS: <br /> ACCEPTED BY: r' EMPLOYEE#: DATE`"-7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: _a r PIE: /+Z� <br /> Fee Amount: e , U�a ' Amount Paid is �� Payment Date <br /> Payment Type Invoice# Check# (� d Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />