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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />HOME Or MkLING ADDRESS <br />SITE DREBS <br />Street Number <br />< <br />Dlr. nn <br />treat Name <br />� v✓ / <br />VI iZI Code <br />HOME Dr � ILING ADDRESS (If Different from Site Address) <br />a,/, <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />(� 1 <br />APN # <br />ACCEPTED BY: <br />LAND USE APPLICATION # <br />PHONE#2 En. <br />( ) <br />DATE: q� ZI <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR\ <br />BILLING ADDRESS❑ <br />CHECK if <br />BUSINESS NAME <br />PHONE# Em. <br />HOME Or MkLING ADDRESS <br />FAX# <br />CITY STATE ZIP <br />J <br />BILLINttek]KNOWLEDGEMENT: 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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: O�� �) 6za y� � inti T DATE: r <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 line or my representative. ftm, <br />TYPE OF SERVICE REQUESTED: <br />s -al 0,,,,7 <br />COMMENTS: <br />WFO <br />-P zo <br />BAN JOAQUINzoz� <br />MgE? H/ pONMENTgL TY <br />ZARTAfEIVr <br />ACCEPTED BY: <br />1 <br />EiMPLOYEEM D <br />DATE: q� ZI <br />/t <br />ASSIGNED TO: I <br />IA <br />I <br />EMPLOYEE #: 3V I <br />DATE: 21 <br />Date Service Completed (if already complete : <br />SERVICE CODE: <br />P, E: tpo <br />Fee Amount: <br />Amount Paid <br />�- a 15a <br />/ <br />Payment Date <br />1 2O 21 <br />Payment Type aag <br />YXIice # <br />I 3 3 <br />1 Received By: <br />EHD 48-02 025 �( V I tK.- fi J a a� SR FORM (Golden Rod) <br />REVISED 11/77/2003 <br />