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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />h��l vy►e 0 <br />�e}s <br />FACILITY ID # <br />SERVICE REQUEST # <br />n2up <br />OWNER/ OPERATOR <br />CITY I , STATE ZIP r I— <br />CHECK If BILLING ADDRESS� <br />FACILITY NAME <br />EMPLOYEE M <br />DATE: 14 / ,? I <br />Date Service Completed (If already completed): <br />SITE ADDREEESSS <br />1 u tJ Street Number <br />Direction <br />Q� /Q�'7/�� yyyrrr��� <br />'bU 3tree e <br />Fee Amount: 1 <br />00 <br />City <br />✓ �J, / <br />S 2 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Invoice # <br />Street Name <br />Received By: °y <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICTLOCATION <br />CODE <br />9.11 rA <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ftAyr�j� <br />CHECK If BILLING ADDRESS <br />Sin Y V- [ty\Of `/1 <br />BUSINESS NAME <br />PHO EXT. <br />5 w► <br />HOME or MAILING ADDRESSFAX# <br />'5 -+';+pad C NIP,. S <br />ACCEPTED BY: � v <br />CITY I , STATE ZIP r I— <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 ch ges associated Ith this project <br />or activity will be billed to me or my business as identified on this form. a� <br />4\@ WVAbaV'CWke,- [off <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, TE and FEDEWIM S. ^, <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT $�� <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tit" <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. <br />TYPE OF SERVICE REQUESTED: Now ChF'cl <br />qY <br />COMMENTS: <br />4tAAJ ean�i��ercd �ef�IL <br />CE�VE <br />SANAPR 0 1 2021 <br />H ENV/ROHM COUN <br />�ALTf/ OREIV <br />ACCEPTED BY: � v <br />EMPLOYEE #: <br />DATE: 1 / .7 / "WENT <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: 14 / ,? I <br />Date Service Completed (If already completed): <br />SERVICE CODE: C 3 <br />P 1 E: q j L) <br />Fee Amount: 1 <br />00 <br />Amount Paid <br />✓ �J, / <br />Payment Date <br />Payment Type 1 <br />Invoice # <br /># 2 t <br />Received By: °y <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />