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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3IL <br /> �s <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAM <br /> SITE ADDRESS1-7% a(/ �)w v <br /> (� Slt Nt N4mber Direct lon Streat Name (�/ \ / CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> © CHECK If BILLING ADDRESS <br /> BUST ESPN / PHONE# <br /> S <br /> HOME or MAILING AD RESS FAIL# <br /> ( ) <br /> CITY STATE LP 2 <br /> BILLAG ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this applicatiy nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and 'EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ N GER ❑ OTHER AIfrHORIZED AGENT I; <br /> IfAPPL/CANT is not the B/LLINGP 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 ENVHtoNMENTAL 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: Q .�f�I ' //�,''� �/� <br /> COMMENTS: �I G!./S `¢` O a4 \ ' l '+I7-Y' Z �&@ eb <br /> j j''Slull �li;/I SANj Q�3 2021 <br /> 1147, NAf CDUN)y <br /> ACCEPTED BY: EMPLOYEE#: IA1 DATE: ? �. <br /> ASSIGNED TO: EMPLOYEE#: I flA J DATE: J <br /> Date Service Com eted (if already completed): SERVICE CODE: P, <br /> Fee Amount: 34 Amount Paid 3 v-1 — Payment Date 3 2 <br /> Payment Type CAU Invoice# Check# 2CQ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 95 til 10"3(Amp � P�3(yo7�-fib � <br /> 11''°° Y r <br />