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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />©ozs 32-50cV3 <br />CITY STATE ZIP <br />O NER/OPERATOR <br />OCT 0 5 2021 <br />CHECK If BILLING ADDRESS <br />r� <br />SAN JOAQUIN COUNTY <br />FACILITY NAM�F� <br />-_ <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />C� <br />Zv <br />SITE ADDRESS •�I <br />C <br />EMPLOYEE #: <br />V <br />Stab, <br />ASSIGNEDTO: �An Ir( <br />EMPLOYEE#: <br />Street Number Dimetlon' <br />Sh/eAat Nama <br />SERVICE CODE: O <br />2`17C`.ddee <br />HOME or MAI NG ADDRE S (If Different from Site Address) <br />O/ <br />Amount Paid <br />y <br />Payment Date <br />Stmet Number <br />Street Name P` <br />CSTATE <br />' <br />ZIP <br />PHONE#1 <br />APN# <br />LAND USE APPLICATION <br />(e103) 956 5/9-3 <br />PHONE #2 Ems• <br />( ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR V _ <br />,�}/ J CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards Sr and FEDERAL laws. n J <br />-APPLICANT'S SIGNATURE: � ADATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT is not the B/LLING 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 environmentaVsite 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, pAYMENT <br />TYPE OF SERVICE REQUESTED: <br />RECEIVED <br />COMMENTS: <br />OCT 0 5 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: S <br />EMPLOYEE #: <br />V <br />DATE: <br />ASSIGNEDTO: �An Ir( <br />EMPLOYEE#: <br />3wI <br />DATE: I{1 <br />Date Service Completed (if already completed). <br />SERVICE CODE: O <br />P/ : 0 <br />Fee Amount: <br />Amount Paid <br />`S� Z — <br />Payment Date <br />Payment Type l <br />Invoice # <br />l "#r 52 <br />' <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />