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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> f - � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS IV _ f n� <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 2 / 9 <br /> Street Number Street Name <br /> CITY / / STATE / � ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> Lf <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORM /`� Grp 1\ CHECK If BILLING ADDRESS❑ <br /> S � <br /> BUSINESS NAME ' I PHONE# EXT. <br /> l'I V NYY,I ) hCC-l/,l ('/"r;�i ,: <br /> HOME OP MAILING ADDRESS f` �� L FAX# <br /> CITY / STATE +k— ZIP L�1� (� / ) <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 Codec,Standards, STATE WuFEDERAL laws-.-" <br /> APPLICANT'S SIGNATURE: -� DATE: e )z ZU <br /> PROPERTY/BUSINESS OWNER El 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. <br /> TYPE OF SERVICE REQUESTED: _ jr PAYMENT <br /> COMMENTS: DECp <br /> Dq 1 8 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ) MPLOYEE#: DATE: Z <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Ci Payment Date <br /> Payment Type V Invoice# Check# vd �j 2/0 S-� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />