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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> X SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR j) / r r CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 5f f—�' <br /> SITE ADDRESS �, `�J �� SC�(0�•t �s <br /> i J ()f Street Number DI ectlonStreet Name Clt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C{ Street Number Street Name <br /> CITY STATE ZIP <br /> PHO E#1 ,� �_ EXT APN# + % LAND USE APPLICATION# <br /> ZZ (xf `�� <br /> PHONE#2 EXT. BOS DISTRICT /' , / LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CN <br /> /' ' `1 a AA _ CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE . EXT. <br /> '5�laV'Wf-x 7 - 7Kv7 <br /> HOME or MAILING ADDRESS �r FAX# <br /> jF60 r�lrlttl KCl. ( ) <br /> CITY \R1 STATE /'/) ZIP 9 J 3 76 <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 la s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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: 1 <br /> COMMENTS: VAYMENT <br /> RECEIVED Z <br /> AUG 14 2020 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: EPARTM IKTE: <br /> ASSIGNED TO: �/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Ob ' P 1 E: 202 <br /> Fee Amount: Amount Paid l 2 Payment Date l <br /> Payment Type Invoice# Check# (D 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />