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, 1/ <br /> SAN JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property W FACILITY iD# SERVICE REQUEST# <br /> �� f0CeS5 n- � b�15�►1kn� S�fI" �-' `(� '� `�, �L � (��-�� ��� <br /> OWNER/OPERATOR <br /> h / CHECK if BILUNG ADDRESS - <br /> FACILITY NAME <br /> let 17 19- <br /> SITE ADDRESS —�1 mQ/r�e �� J fC�k/QYJ 9SZ�� <br /> Street Number I D16rection Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) J -D-72 3 Z— <br /> Street Number Street Name <br /> CITYk�n G TE ZIP 6 y/� <br /> o <br /> PHONE#1 Exr• APN# LAND USE APPUCA71ON# <br /> ( ) (ip - - <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILUNG ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> e � <br /> HOME Or MAILING ADDRESS J / FAX# <br /> CITY 4-6 G STATE C 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 certity 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,S"FATE EDERAL IawS. <br /> APPLICANT'S SIGNATURE: DATE: O <br /> / l �D/]Z <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ J' 6L��rs'� CI (/L4i C'(lI'7 <br /> IIAPPLICAtVT 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: <br /> COMMENTS: <br /> �EIVEo <br /> APR 17 2020 <br /> ACCEPTED BY: Cid \ EMPLOYEE#: DAO IN CO,UN� <br /> ASSIGNED TO: \ C(—\ <br /> � \ �X EMPLOYEE#: DATE: EPf>RTMEN <br /> Date Service Completed (if already completed): SEIMCE CODE: \ P 1 E: \� <br /> Fee Amount: (VVT I <br /> Amount Paid Payment Date <br /> Payment Type Invoice# Check r77/0 3 Received By: <br /> EHD 48-02-025 �� h—] l�O SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />