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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ,Tppype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �`tG lot k V"2 0� Jl� �� g �1-6QV(l <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> r' <br /> FACILITY NAM <br /> SITE ADDRESS �n icer, �� San rK <br /> ✓�031Z GStreet Number I DirectionJVI A.�am. <br /> Y` Clt ZI Cotla <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Te Street Number Street Name <br /> CI STATE ZIP 952 _' <br /> r`,'1 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# C/� <br /> an ) � I — \� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR(� <br /> t e CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# —�I EXT. <br /> t <br /> HOME orAIIAILIN <br /> ADDRESS FA%# <br /> M/J ( ) <br /> CITY STATE ZIP !'I <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 s. !J <br /> APPLICANT'S SIGNATURE: DATE: G v o <br /> PROPERTY/BUSINESS OWNER fI 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: <br /> COMMENTS: <br /> RECEIVE® <br /> OT atAJUrP"n saNAU624 2020 <br /> Ft ENVIRONMJOAQUE OUN7Y <br /> ACCEPTED BY: EMPLOYEE#: 3 U DATE: R �� <br /> ASSIGNED TO: EMPLOYEE#: 3 3('d <br /> DATE: 7�v <br /> Date Service Completed (if already completed): 1. SERVICECODE: l.P I P I E: <br /> Fee Amount: �•O� Amount Paid / a ! Payment Date <br /> i <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />