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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TA 00 I sa SQ 0.D81- g <br /> OWNER/OPERATOR <br /> C CHECK If BILLING ADDRESA4 <br /> FACILITY NAME S t� <br /> SITE ADDRESS \P�c�G,6�\�, \p ���,�� �3"3 <br /> StreeGt�Numbar DlreWctlon I T\ Stree\t'NCama V� Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t Number Street Name <br /> CITY STATE Zip <br /> roJ <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMESt�� PHONE# — E '. <br /> Y 8 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY dtiSTATE('„ ZIP r� <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,STATEED AL la ) <br /> APPLICANT'S SIGNATURES �o DATE: 9/Lnj/12 , <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> /f APPLlcANT is not the BILLING PART r 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. in,g <br /> TYPE OF SERVICE REQUESTED: C, sLeRjFN <br /> COMMENTS: sFP ED <br /> 4w��-�S�u� �3 2021 <br /> C t QUIN COU <br /> n Ii THDE MAL 1Y <br /> ACCEPTED BY: Ill\ EMPLOYEE DATE: ' <br /> ASSIGNED TO: 1' EMPLOYEE#: DATE: <br /> Date Service Com eted (if already completed): SERVICE CODE: I P/,E: iloo <br /> G <br /> Fee Amount 1'V -2 - on Amount Paid /52 �V Payment Date l 23 <br /> Payment Type�efl Invoice# I Check# 32 _ Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />