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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> q fz oo�Z2 IS <br /> OWNER I OPERATOR <br /> �-v CHECK if BILLING ADDRESS <br /> FACILITY NAME Co a&�,J t,,C, -� <br /> SITE ADDRESS J"112 t t1 e � <br /> Street Number i action tre Cit 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) i -�, 1 1�3/`41 e' '�700c G SL <br /> Street Number Street Name 1 <br /> CITY rV\AV1 OCG STATE �jl ZIP Cl <br /> PHONE#1 r jZ EXT. <br /> APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR , 1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME �\/I n n A \ n PHONE# <br /> tl'C C ►V 1, Ty C ire fig.r�/l� 2 ��-_Z Z Lo I <br /> M. <br /> HOME or MAILING ADDRESS FAX# <br /> WL"�P- 'r-u a c -r- s I- ( ) <br /> CITY (A VVV (A 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 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 F RAL laws. <br /> APPLICANT'S SIGNATURE: �C � �' - ��� 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 <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. ft <br /> ew- <br /> TYPE OF SERVICE REQUESTED: GI y Q/�L 11`C C' '�GI, RF T <br /> COMMENTS: 0 w JUN Af <br /> 8 2020 <br /> N'JDAQU/ty <br /> MF.9L y p�pU ��IY <br /> T <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I <br /> Fee Amount: + 1 Z 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 />