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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type o usiness or Property FACILITY ID# VSEr-RRVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK 11 BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS h� l (� //`N � �t / ���'7 <br /> Street Number Direction �r r �08 rf eet NariTls — / Cit [L � F��ipCode <br /> HOME or MAILING ADDRESS (If)Rifferent from Sit ddress) <br /> // / ir l *G-" a17— <br /> Street Number Street Name <br /> CITY C.— CC+0AJ NATE :,S 9 <br /> PHONE#1EXT. APN# LAND USE APPLICATION# <br /> ) 1k <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` CC2 / CHECK if BILLING ADDRESS■ <br /> BUSINESS NAME Vl PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> C�n <br /> CITY S� G Y1 O Zv kC J Gth `1 C— / STATE - ZIP <br /> BILLING, V(1 ACKNOWLEDdEMENT: I, the undersigned property or busine s ow perator or authorized agent o sam <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 th wank to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED L laws./ <br /> APPLICANT'S SIGNATURE: DATE: <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: P <br /> COMMENTS: <br /> F06vpn <br /> 410 <br /> MAR 052020 <br /> SAN vIARC,QUIN COU <br /> N N7Y <br /> ACCEPTED BY:Cn 0' -L EMPLOYEE#: DATE: <br /> ASSIGNED TO: v. CLe M a'La EMPLOYEE#: DATE: 2 <br /> Date Service Completed (If already completed): SERVICE CODE: Z PIE: \t n� <br /> Fee Amount: Amount Paid Payment Date Q `+G <br /> Payment Type �A• Invoice# Check# Received By: <br /> EHD 48-02-025 1. �+C SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />