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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 11 1) CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME t <br /> SITE ADDRESS /V,i may/ y 3? <br /> Z�-b Sv S �;�Y i3)�d, <br /> Street Number Irectl n Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> srA Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> 2 :� -Sao-s3 p,4-/�'�W7664 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> M�r'iG �crreS <br /> BUSINESS NAME PH(N.E# EXT. <br /> 5� (o`f� -gy Sv <br /> HOME or MAILING ADDRESS FAX# <br /> 35et ,Ife e <br /> CITY 01 (-<r ` STATE L/Ar' ZIP c� <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: VVI- DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT r/p1�( �L✓T �►� <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: b <br /> E1VEp <br /> JUN 9 2020 <br /> SAN JOAQUIN <br /> HEALTH p NMEN-AL TY <br /> fuACCEPTED BY: EMPLOYEE#: DATE: L <br /> ASSIGNED TO: ` ^ EMPLOYEE#: C/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 2(p 2 <br /> Fee Amount: U Amount Paid Payment Date -�LQ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />