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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 I OPERATOR �" <br /> p �i�a 6.n L1- a Ae4 P I'm`M+ CHECK if BILLING ADDRESS❑ <br /> ' <br /> FACILITY NAME L�,� ro C L-�u'= Z d 1<2 <br /> SITE AQ SS S <br /> t� /Zv. I !�}� �—oL <br /> Street Number D reetlon treetlJame c 19,152- <br /> l Zi 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 /> ve,q] 1 05 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME t G� � � / _n l i� PHONE# - ExT. <br /> HOME MAILING ADDRESS v FAX# <br /> CITY / e) /I 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 an EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUsmFss OWNER❑ OPERA74R/MANAGER OTHER AUTHORIZED AGENT❑ L7E,AIE �1 / !✓yQy�✓ <br /> If APPLICANT is not the BILLING P,4RTY 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. cam, , { <br /> Jr <br /> TYPE OF SERVICE REQUESTED: C(J�(l�vl l L /� R ,r <br /> COMMENTS: ,,-� 1 J �G7X),a J 'I`�)'J ❑ <br /> //T Y p 4 2020 <br /> SAN <br /> � jO <br /> NlpCU11y <br /> rY3 ~Z.0 01 �0 j Mb pN <br /> RrMEUT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed); SERVICE CODE: O u P 1 E: 2 <br /> Fee Amount: 1�7 Amount Paid J a Payment Date L 25 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ` (} lIG"l UvI SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />