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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICg REQUEST# <br /> 3131 <br /> OWNER/OPERATOR <br /> kA CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS OX <br /> rr`v <br /> Street Number Direction straot Nam <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street <br /> CITY STATE zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ('ate) --Y-Ac� 5-:'(o <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY T STATE C V)V zip <br /> BILLING`ACKNO DGEMENT: 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,STA// and F ERAL laws. <br /> APPLICANT'S SIGNATURE: V <br /> C/ DATE: <br /> PROPERTY/BUSINESS OWNER OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR77'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 /> CO MIIENTS: C�,ti o.J,,rr C ri a p ED <br /> SAN 1 SEP 0 g 2020 <br /> E�NJOA NHE ROMECOUNTY/DepAAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � a EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q PIE: <br /> Fee Amount: 5 2 , - Amount Paid D Payment Date �D <br /> Payment Type ccInvoice# Check# 1137z-_ 137 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> I{1���5�3 �_ � <br />