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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE # EXT. <br />FACILITY I # <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />FAX# <br />CHECK ((BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />Stree umbar <br />Dlreetlon <br />Street Name <br />CIl <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PH0NE#1 <br />EXT' <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�" CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME AILING AA_,j�RE55 <br />C <br />FAX# <br />( ) <br />CITY ` STATE G� 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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATU- DATE: <br />PROPERTY/ BUSINESS OWNER❑ OP TOR/MANAGER❑ OTHER AUTHORIZED AGENT 13 <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 attie same time it is <br />provided to me or my representative. _ AYAS&, <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />OCT o 1 jo 2021 <br />q�IROUIN CO <br />NF,gl7HOE L <br />ACCEPTED BY: A Q0 EMPLOYEE #: 5 DATE: [U , L' <br />ASSIGNED TO: t. EMPLOYEE #: / DATE: <br />Date Service Completed If already completed): SERVICE CODE: � P I E: I Po J <br />Fee Amount: V VV Amount P ' '� D Payment Date e / H <br />Payment Type, n 4;+ 1 Invoice # I I Check # / j ���f'J 2/ Receiv d By/ <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />