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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> / SERVICE REQUEST <br /> Type of Businessr or Property -FAACILITY ID# SERVICE REQUEST# <br /> 13QDO 193 0LI <br /> / OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME /� �,/ <br /> SITE ADDRESS (C �/ (i/ �—q l _ / _/may�/p/ 91-�� <br /> Street Number Direction St/reef Name CJ 4-GL�4�C`I(i�` '/" l ` Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> iy Street Number Street Name <br /> CIN �/ STATE ZIP <br /> („"( G S <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> q af ) 621- 1�"5- 1 ipc:21 3100(0 <br /> PHONE#2 Ex . BOIS DISTRICT L ON CODE <br /> o 1 cu <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EZ . <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,Standards, STATE and FtDEFAL laws. <br /> may/ <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZ 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available qjLd_at the Same time it is <br /> provided to me or my representative. - y <br /> TYPE OF SERVICE REQUESTED: - �".%'tavPA <br /> COMMENTS: <br /> R 12 2021 <br /> &WtJORQUItV ON&FCOO <br /> NF� ty <br /> THDEPARTM N� <br /> ACCEPTED BY: { C EMPLOYEE III: DATE: <br /> ASSIGNED TO: /. EMPLOYEE#: DATE: JJ L <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P/E: 02w- <br /> Fee Amount: 1 SZ Amount Pal ��� �V Payment Date / � F�� <br /> Payment Type L/�76 Invoice# Check# Received By: <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />