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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property fin] FACILITY ID# SERVICE ERRE{/QUr ES # <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS E] <br /> ParA A P ts- <br /> FACIL ME I U R rJ v I y�W <br /> SITE ADDRESS` ltl (—(,, 95y l 9 <br /> b 9 Street Number Direction Street Name CI 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( i <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR tel/ V <br /> U O 99 CHECK If BILLING ADDRESS <br /> BUSINESSNAME� PH <br /> ikrA,e-t4s (�U lasa,er�h o9# 62 'f • 291 � EXT. <br /> HOME or MAILING ADDRESS ( t �^ (Ax# ) <br /> O a64 <br /> CITY STATE ZIP 5-?6 <br /> BILLING ACKNOWLEDGEMENT: 1, 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: —4/ DATE:�-(/ <br /> T- 2 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHIORizED AGENT 11 <br /> If APPLICANT iS not the Bit LING 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 /> IrM <br /> TYPE OF SERVICE REQUESTED: ( C IQ �� <br /> COMMENTS: •�, " /� ` f//`11 n�n AD <br /> SANJO _ '8 2020 <br /> 1 N EN�RQbtNC <br /> EACTyDpyEtvg Ty <br /> ART,HENT <br /> ACCEPTED BY: S EMPLOYEE M DATE: <br /> ASSIGNED TO; r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� PIE: / ✓� <br /> Fee Amoun Amount Paid 3 D Payment Date �7. <br /> Payment Type r Invoice# Check# Received By: <br /> EHD 48-02-025 ,/+ �•D SR FORM(Golden Rod) <br /> REVISED II/17/2003 T G.3 Qb(>5 -1 <br />