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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �R0©ga.� o ( <br /> OWNER/OPERATOR . <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Z(fAfQ t SCOL <br /> SITE ADDRESSLG / <br /> J ��ei �,v �� P <br /> Street Number Dlrec Ion Street Name city Zip Code <br /> HOME or MAILING ADD SS (If Diffe�rent-fr1om S' Ad ress) <br /> t � CL/ / t/Pv Street Number Street Name <br /> CITY STATE ZIP qPCLO <br /> PHONE#1 ETT. APN# LAND USE APPLICATION# <br /> ( ?09) 2ic 66 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS E] <br /> BUSINESS NAMEL_ — En.UN, - PHONE# <br /> HOME or MAILING ADDRESS /� J /c J FAX# <br /> 7 N �L (/ ) <br /> CITY i C C�/ / �J STATE C� 4 ZIP <br /> BILLING ACKNOWLEDGEMENT: 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,STATE and FEDERAL laws. <br /> PPLICANT'S SIGNATURE: / r�� -�"� DATE: �O z zy <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 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. A{, <br /> TYPE OF SERVICE REQUESTED: ✓O O O N/7N '77 <br /> COMMENTS: <br /> act 29 <br /> svvJoq 2020 <br /> H FNVjRQIJ COU <br /> /V <br /> TY <br /> ACCEPTED BY: �(� EMPLOYEE DATE: LO 2-�b <br /> ASSIGNED TO: �� Ml �jj EMPLOYEE#: DATE: l O - 2-9 �y <br /> Date Service Completed (if already completed): SERVICE CODE: b t•7 P 1 E: l ( <br /> Fee Amount: Z i7� Amount Paid /�a.J Payment Date OI 2� I ZO <br /> Payment Type Cl (7�n Invoice# Check# Received By: <br /> EHD 48-02-025 l� - I I W I�I(J�" ( SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> t <br />