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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PR O 1(o O 1 (n 4 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME % / ` <br /> SITE ADDRESS / +I M�}(/� e- <br /> 12 <br /> / 1-7 Street Number uctlon Name �� / <br /> Hoyle Or MAILING�BpRESS (If Different from Tie Address) <br /> '� (1\ Street Number Street Name <br /> CI STATE ZIP <br /> i <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 7r <br /> n8E 2 3? D 1" <br /> BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME • O PI�pNE# S EXT. <br /> so C <br /> HOME or MAILING ADDRESS FAX# <br /> 21 g ( 1 <br /> CITY Lt=h4 <br /> 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 ap lication and that the work to be performed will be done in accordance With all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST Tan FEDERAL S. <br /> PPLICANT'S SIGNATURE: DATE: b G Z <br /> PROPERTY/BUSINESS OWNER OPWRATOR/ A ❑ OTHERAUTHORT DAGENT❑ <br /> IfAPRUCANT is not the ILSlLLINC PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INTFORMATION: 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. P <br /> Ayisp- <br /> TYPE OF SERVICE REQUESTED: RZ6 <br /> COMMENTS: 7-A,,.25 fr-r 16 aW�re� JUN 2021 <br /> ENWROUiN lvilf COUN7y <br /> HEiI <br /> ST H O P'R..NT <br /> ACCEPTED BY: it EMPLOYEE#: DATE: W' n ni1 I <br /> ASSIGNED TO: EMPLOYEE#: "2� n I DATE: ��'1 <br /> Date Service Completed (if already completed): SERVICE CODE: v P E: , v 2 <br /> Fee Amount: Amount Paid a./ Payment Date 1(0 1 2I <br /> Payment Type opa Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />