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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# En <br /> ERVICE REQUEST# <br /> „ SVY GLi nk� OI�UU?2 2i <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �J (��y� M Pr„ ,OV C' <br /> /SRre�Number Direction JStreetC /” a� <br /> HOME or MAILING ADDRESS (ifDiff rent from Site Address) <br /> G / Street Number Street Name <br /> Cl STATS ZIP _ <br /> ,r e 6,09 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> HONE#2 EXT. BO DIST ICT LOC�TI CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME PNONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> n� ✓` ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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: �j-7 /- DATE: <br /> PROPERTY/BUSINESS OWNERS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY proof Of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 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 /> JUL 14 2020 <br /> f Z RO i COON <br /> M�THO PART?Hy <br /> ACCEPTED BY: v°J EMPLOYEE#: l'7 0 o DATE: -7 'l l 20 <br /> ASSIGNED TO: ✓'• U EMPLOYEE M97-7 DATE: -7j/LJ /2-0 <br /> Date Service Competed (if already completed): SERVICE CODE: P I E: iW <br /> Fee Amount: 5 U Amount Paid Payment Date -711 <br /> Payment Type Invoice# Check# Atecel6d By: <br /> V � V <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 c� <br /> M052i,p-730 J <br />