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" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT U L S Jai bl I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �- C'C . DOVS- Z <br /> OWNER I OPERATOR <br /> 1 CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSISStreet Number t <br /> Direction 0I 1 I et Nama `Y'1`Ootlel�"• <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EIT, APN# LAND USE APPLICATION# <br /> PHONE#2 Ezr. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' <br /> PHONE# 3Exr. <br /> � l- <br /> HOME or MAILING ADDRESSFAx# <br /> ox w J <br /> I ( ) <br /> CITY =.�}- STATE zip 9 <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,StandardsXgcl-1 <br /> and FEDE laws. <br /> APPLICANT'S SIGNATURE: 7x/! DATE: � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C3 <br /> If APPLICANT is not the BILLINGPARTP 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 t same time it is <br /> provided to me or my representative. PAYMEN11 <br /> TYPE OF SERVICE REQUESTED: ( Y tAJ w-\-/ R <br /> ECENhu <br /> COMMENTS: .-rB 03 2022 <br /> SAN <br /> AENVIRONITM <br /> MENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I/I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O-� PIE: <br /> Fee Amount: Amount Paid l Z _ Payment Date y 9jy <br /> Zi7 Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />