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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S X00 �y2 W <br /> OWNER/OPE TOR <br /> CoCHECK It BILLING ADDRESS <br /> FACILITY NAME LJ�/ ,J <br /> TE DRESS q <br /> ✓Sth6ttt'uY eP' on t 6t""""v "" 1 ade"/�0 <br /> Ho7r LIN DDRtcr�¢�� (If rent from Site to <br /> ) <br /> l/ Street Number Street Name <br /> C ST ZIP <br /> 1 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 PONE EXT, <br /> l O <br /> H7 O,rJLN AD ESS FAz# <br /> �' 1 1 <br /> CINSTAT C�_ ZIP- h \ 6 <br /> &1145 1 <br /> BILLING ACKNOWL DGEMENT: 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,Stan ards STATE and FEDE laws. I? l\1� <br /> APPLICANT'S SIGNATURE: ` DATE: 7/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 0 OTHER AUTHORIZED AGENT El <br /> IfAPPLIcANT is not the BILLING PAR TYproof ofauthorization 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: 9 m PAYMENT <br /> COMMENTS: <br /> SEP 21 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: VWVw EMPLOYEE#: DATE: � 2I Z <br /> ASSIGNED TO: S <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: rm P/E: WS <br /> Fee Amount: `C5 Amount Paid S2 Payment Date q12-11 2 <br /> Payment Type Invoice# lf�%!132Dq4Y Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �'� ,v Z <br />