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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =4a� <br /> ERVICE REQUEST# <br /> ylUwvg ;�$O <br /> OWNER CIPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE.ADDRESS <br /> RI <br /> YL Street Number Direction Street Name " � Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /5DZ- 0', <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. _ APN# LAND USE APPLICATION# <br /> zq <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �7 „ <br /> omaz CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> © g')[( <br /> HOME or MAILING AJQDRESS FA%# <br /> /502. <br /> CITY O `, ` STATEen ZIP Ci <br /> G <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 /> 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: gyp ^ t DATE; ?/Z'R60zo <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT 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 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: T V ( ,v1S _ PAY <br /> COMMENTS: (�' ^rA D f� RECEIVED <br /> vv(�V tl' 10L 2 8 2020 <br /> SAN JOAQUIN COU <br /> ENVIRONMENTNTy <br /> MEAI.TN DE A <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: G EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed: SERVICE CODE: PIE: O <br /> Fee Amount 1 C5-Z� Amount Paid R.— <br /> Payment Date �K2 P 2 O <br /> Payment Type Invoice# (/Gheck#- Received By: <br /> EHD 48-02-025 I ` OlL)� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />