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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII 1 YID# SERVICE REQUEST# <br /> ZratleA --,o -To be c o �? Gr�c�N F�rc 1 S'�0 9\9 oc� <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> FSITE ADDRESS l f7CC� �� C�C N ' S-;2o <br /> �O <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILIN ADDRESS (If Different from Site Address) �U G Ge��� —IgNC <br /> o Street Number Street Name <br /> CITYP Y . Z STATE ZIP` <br /> 3 4 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( �o Go7 6o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 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 S FEDERA Ll aws <br /> APPLICANT'S SIGNATU l Q vt�e DATE: D'? -2-o <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 propertylocated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or � e assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is av� same time it is <br /> provided to me or my representative. ED <br /> TYPE OF SERVICE REQUESTED: NJ'—`IA 0&1w j ""AN <br /> 18 2020 <br /> COMMENTS: SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH D,!"PARTMENT <br /> ACCEPTED BY: L(l t-'A c' c> EMPLOYEE M DATE: 2J 2 b <br /> ASSIGNED TO: C�✓ �� a EMPLOYEE M DATE: 3 / <br /> Date Service Completed (If already completed): SERVICE CODE: v' r P 1 E: <br /> Fee Amount: O 1 Amount Paid (�a i Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 �#*'l U(Q g5021� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 l <br />