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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��bO JJDD <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME , t� <br /> SITE ADDRESS Q-.41--1�1J�O S'T— t,.6 �t l <br /> S <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> r5 ZS i c��ZtJ cc t <br /> Street Number Street Name <br /> CITY _ STATE ZIP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> tet,s 11 CHECK if BILLING ADDRESS <br /> BUSINESS NAME �Jn PHONE# Exr. <br /> HOME or MAILING ADDRESS ` FAX# <br /> �� SOI? LC?J INC- ( ) <br /> CITY _ ' STATE C4 ZIP 'TS Z <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 Coder,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER❑ I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR TY.proof ofauthorization 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: M ( ,Q n RECEIVED <br /> COMMENTS: MAR 11 2021 <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: 3 U DATE: 2 'I /L <br /> ASSIGNEDTO: EMPLOYEE#: DATE: 3 / y <br /> Date Service Completed (if already completed): SERVICE CODE: WP E: +11 0 03 <br /> Fee Amount: Amount Paid ifL S Payment Date <br /> Payment Type r Invoice# �Iee cr# 1 Z Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />