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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA o M 1,91 q %Z 00g 31 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> ftmtE�' i'a-. C r' i S <br /> FACILITY NAM <br /> M Tiros <br /> SITE ADDRESS /�✓) /'�/ {,^ /'-� p <br /> Street Number Dl • ' ?street NALORZip Code <br /> e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> umber Ira e <br /> Street N <br /> CITx STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (7cq) g2 g;> OV+ 01 OD k <br /> PHONE#Z EXT. BOS DISTRICT oo+ ' LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <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,Stan ST TE and F D AL laws. <br /> APPLICANT'S SIGNATURE, DATE: (7� <br /> PROPERTY/BUSINESS OWNEIt2 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, 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 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 P <br /> TYPE OF SERVICE REQUESTED: CfSY��/V�M4�►'�/�`r �C <br /> COMMENTS: <br /> .14N 13 2021 <br /> eQUIN C <br /> °po14 <br /> ACCEPTED BY: S EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C(„ P I E: 1� <br /> Fee Amount: `cJ2� Amount Paid vJ Payment Date L3(2A <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 �" SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />