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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gi2` oozzq-�; <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) p A V <br /> 15 I Street Number `SLS Street Name <br /> CITY STATE Zip r <br /> 5.1-O�,fG 4 435 ;?o6 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (qoF) 5.75 _ 3 /si 1 '73 - 09-01-3 <br /> PHONE#2 EXT• BOS DISTRICT LOCATIO_N__C.ODE— <br /> ( ) 7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Ex-r. <br /> ,n ►ti. e-,�.->�� 7c L/(o <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY '] STATE 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,Standard,ST-AT-B-ate I <br /> APPLICANT'S SIGNATURE �— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT tp, <br /> If APPLICANT is not the BILLINGPARTY,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 /> COMMENTS: .�`fif'C.� � fV( 'I—rs✓�..� �cs-�-[�1.�Y�'1 N�QJN� t�c..� is� �.�.,t,�-s RFc MFj yT <br /> Nov <br /> %J0 ?5 2020 <br /> EIy�RQUtjyC <br /> 01 <br /> ACCEPTED BY: ����' EMPLOYEE#: DATE: I I SOS ,anrA( <br /> Ir <br /> ASSIGNED TO: S S EMPLOYEE#: DATE: i lids do'12l) <br /> Date Service Completed (if already completed): SERVICE CODE: sa3 P/E. o?g0,-2 <br /> Fee Amount: O8 Amount Paid Payment Date V/2� 20 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />