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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> b000 '� Sk"6 g-K 15 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME A _ 1 I'll <br /> SITE ADDRESS <br /> kP� <br /> ✓1 Street Number Direcilon Street Name CI ZI Cotl <br /> HOME or MAILING AD RESS (If Diifere t from Site Address) <br /> 6 Street Number Street Name <br /> CITY r� STATE r"/ ZIP C_ <br /> PHONE#1T• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , <br /> Q f �u � CHECK If BILLING ADDRESS <br /> 61(l Ll 11BUSINESS NAME,-}— I t V PHONE# EZ . <br /> HOME or MAILING AD ESS _ FAX# <br /> 1470 1 ( ) <br /> CITY STATEo V) _ ZIPS <br /> BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner, operator or authorized agent of same, <br /> !aeknow!edge 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 FEDEFAL laws. <br /> APPLICANT'S SIGNATUrpREE: DATE: // —UZ — a Z C7 <br /> PROPERTY/BUSINESS OWNER VJ OPERATOR/MANA ER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BLLLINGPAKTP 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. -v <br /> TYPE OF SERVICE REQUESTED: �VE� <br /> COMMENTS: <br /> NOV 0 2 2020 <br /> Gma�� Of DuwflrSY) c(' <br /> SA30 <br /> R5ppa M <br /> pN <br /> HEALTH EPAR <br /> ACCEPTED BY: ✓/I S EMPLOYEE#: DATE: lo <br /> 2� <br /> ASSIGNED TO: 1 t/1 EMPLOYEE#: DATE: 1 D2 <br /> Date Service Completed (if already completed): SERVICE CODE: P I <br /> Fee Amount: 6/�' Amount PaidS _ Paymil <br /> ent Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 o <br />