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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> nnREQUEST# <br /> II <br /> ✓ CZ C E r1'7VrVOl�J Iy <br /> OW^NER—{I OPERATOR <br /> G? U t S-,�'w CHECK If BILLING ADDRESS <br /> FACIL)TY NAME - <br /> c eA S <br /> SITE ADDRESS S 70 Cl'` C(t cr .�- <br /> 3 Street Number I Direction heel Name CI ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) M Ir W�.� <br /> Yi Sheet Number reel Name <br /> CITY STATE ZIP <br /> / O C' O1 rJ'),- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR rr /J v l \r s n <br /> )' )' 'C. It. CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> A C F G P,E R Q4%A T- -7 L4 <br /> HOME Or MAILING ADDRESS FAX# <br /> 3kI 4^ rte ' try - V'< 00 s IS 7- of <br /> CIN � ---Q (f TDI✓ STATE ZIP pl S�o�-- <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 0� / DATE: Cl— q--'9,o <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicabie, 1, 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 t0 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: O (I RECEIVED <br /> COMMENTS: SEP 0 ^ 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: / EMPLOYEE#: DATE: 2V <br /> ASSIGNED TO: Wis Vr EMPLOYEE#: 61 <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CGDE: P/E: U'Z? <br /> Fee Amount: V Amount Paid / 5 -,2 _ Payment Date 2-7 �'- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />