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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME A, 4 <br /> �) <br /> SITE ADDRESS 3 2 (� \ <br /> Street Number Direction Street Nam`e\u 1\Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (&I�) 3dI D1 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> ditiiq A,xc,-,L,7 <br /> HOME or MAILING ADDRESS FAX# <br /> r u ( ) <br /> CITYSTATE Zip PAYM ENT 4. ,2 6�' ��2 ( '5— <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized ageuMC VIED <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this roe t <br /> or activity will be billed to me or my business as identified on this form. FES 2021 <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> COUNTY Ordinance Codes,Standards, STATE and FEDE L laws. ENVIRONMENTAL <br /> f HEALTH DEPARTMENT <br /> APPLICANT'S SIGNATURE: L �� G 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 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. -/ / / <br /> TYPE OF SERVICE REQUESTED: vpPf 4 t k t c't,im b A 5e t l t lcyn c:ji /;)7 e � v o5u�e Sf=i� 44t6 S r4 )"t4. <br /> COMMENTS:I\)n rf Ptlt pt/,riits nn rI je - 'Ve't�7 00stuncP a Scpllc tz,r►l h p,aPo�f�,/ aC/t!t ho.,iS. I/err(y <br /> C,(is�c.nce o� IegGti IIhE' � pr�pr�aee� �C.�C�lfror( CALL(209)953-7697 <br /> FOR INSPECTION. <br /> 48 HOUR NOTICE <br /> REQUIRED. <br /> ACCEPTED BY: �� _.... __. DATE: a ltd ) <br /> ASSIGNED TO: DA EMPLOYEE#: DATE: a lI d l <br /> Date Service Completed (if already Completed): SERVICE CODE. J G,% P/E' L� Vol <br /> Fee Amount: �� Amount Paid If 2— Payment Date ` <br /> Payment Type Invoice# Zb5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 , <br />