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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# REQUEST# <br /> jj�ERVICE <br /> 00�Ilp��" <br /> OWNER/OPERATOR FA 000181701 CHECK if BILLING ADDRESS❑ <br /> Ii <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name City ZI Code <br /> HOME Or MAILING ADDRESS Qf Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP qy <br /> PHONE#1 ExT- APN# LAND USE APPLICATION# VE <br /> ( �)r ) I .`':.iii 1 ni <br /> PHONE#2 ExT• BOS DISTRICT LOCAL N CODE 2020 <br /> ( ) �ry dOAQ <br /> CONTRACTOR / SERVICE REQUESTOR HEA 0,.- TY <br /> ENT <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CIN "I`;'.. , _ . STATE f:;:, 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 shargesassociated'with this prgject <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 :D WS. <br /> APPLICANT'S SIGNATURE: DATE: 01 272020 <br /> PROPERTY/BUSINESS OWNER❑ 00�1011`]Elbk'OR/MANAGER ❑ OTHERAUTHORmEDAGENTO AGEPII <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: FLAN REVIEW <br /> COMMENTS: 'le:n tevV 'ya for '1C'!^ .- Off' Irl efl';Iwq i:U1111i1C'IC181 fetall t(?Il;;t11.'n;p"ICe Store upefahorl5 S9'I ';) JU(1f3 <br /> stales of caminelclally�piepackaped roc,-! Item ido coir, . r ;Tal aiInn (JI conslln-;ption to 6 !:uI on LAIL <br /> �i�(''ec``�-P� PLcc.-h 1�v v�2c-ll m i t✓hc e I C�� p qn. <br /> c.o <br /> ACCEPTED BY: Cu fo'K t S -6 EMPLOYEE#: DATE: 1 —2^7 <br /> ASSIGNED TO: F l0 k l S eL, EMPLOYEE#: DATE: X27 -2jD <br /> Date Service Completed (if already completed): SERVICE CODE: —5-23 P I E: C6�J <br /> Fee Amount. 445 r 60 Amount Pai �g OD Payment bate <br /> Payment Type _ Invoice# Check# /e) Z3��J Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />