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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OX4NER/OPERATOR /t <br /> 5 a ' ,n / CHECK If BILLING ADDRESS <br /> FACILITY NAE r/ KJ(/1�..'^(-�(�(�jj't <br /> SITE ADDRESS D�w �e <br /> Street Number Direction `�� act Name city21 Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 'O 900 <br /> e <br /> CITY <br /> STATE ZIP �(y^ f- <br /> PHONE#1 LAND USE APPLICATION# aO( f <br /> 2Nenr#; a I �aaT O _�� J 111Aa` BOS DISTRICT LOCATON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ham Dq��L ,5(oill <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /I.lYln PIONEI. <br /> 0 Sag <br /> MM or M FAX# <br /> > r7D )a55D <br /> ITY n �n/{ I� STATE N ZIP <br /> BILLING 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 /> 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 I and ! – �^r^// 'I <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' P — DATE: y��'i IA m <br /> IF I <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> tf APPL/CANT 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 and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: i f a Tn.. PAY M E N T <br /> COMMENTS: V E D <br /> MAR 10 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTV qFpAgTr,1rmT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ^ 2 I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SEWCECODE: PIE: I ,� <br /> Fee Amount: Amount Paid ` SZ — Payment Date <br /> Payment Type Invoice# Check <br /> iiiI# n t ps7 Received By: <br /> EHD 48-02-025 y��� 0 1 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1 <br />