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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESST# <br /> —F oQu <br /> OWNER/ OPERATOR � I i <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME W 1111II��� xxxTTT��� <br /> SITE ADDR/hEESS �`' T��U <br /> V Street Number Direction 1 Street Name 1 Cit Zi Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CNG S Street Number Street Name <br /> CITY STATE ZIP <br /> - t!� 6)53o . <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (W ) o(p - 3,(9 7 Z55_ 3(o — 2Z <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> ( 70 A <br /> HOME or MAILING ADDRESS FAX# <br /> S <br /> CITY STATE ZIP 9530+ <br /> BILLING ACKNO LEDGEMENT: 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, S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE• DATE: <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 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. I' <br /> TYPE OF SERVICE REQUESTED: PI o Pc l= Nni 1Yl F FYP(% S '<�Q' ) PAYMENT <br /> COMMENTS: �11 I RECEIVED <br /> Dv-1 CZ 7/OIR.�-A <br /> n� <br /> DEC 10 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � � v EMPLOYEE#: DATE: I3 1J,bU <br /> ASSIGNED TO: LI/► ` EMPLOYEE#: DATE:/ah'U dpgo <br /> Date Service Completed (if already completed): SERVICE CODE: C a 3 P/E, a0 <br /> Fee Amount: 3�L) Amount Paid j Payment Date <br /> Payment Type i Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />