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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PSSv► 'Kr �0r I �10 S QQ X31 <br /> OWNER/OPERATOR <br /> U CHECK if BILLING ADDRESS <br /> FAC/LL NAME <br /> SITE ADDRESS S t <br /> DV Street Number Direction Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (if <br /> �Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> a G, as <br /> PHONE#1 EXr. APN# LAND USE APPLICATION# <br /> ('�o ) gq-3465 <br /> PHONE#P EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 15 <br /> l,,,,t p CHECK if BILLING ADDRESS <br /> BUSINESS NAME ��� `� PHONE# EXT• <br /> HOME Or MAILING ADDRESS 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 STAT and FEDERAL laws. /7 <br /> APPLICANT'S SIGNATU DATE: 'v <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 g�Wne, e it is <br /> provided to me or my representative. M MC�1�V <br /> TYPE OF SERVICE REQUESTED: —p . Q <br /> COMMENTS: OCT 18 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: j 3 DATE: 14 )(-15 <br /> ASSIGNED T0: ' ulvv— EMPLOYEE#: DATE: 1011:g /z) <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: Id2Fee Amount: Amount Paid S 2 _ Payment Date <br /> Payment Typera Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 0 rN <br />