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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Ce 5 <br /> FACILITY NAME <br /> SITE ADDRESS ' <br /> / ^ r �p - J / s G � �• f TSQ <br /> Street Number Dl rection Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> PHONE #2 EXT, BOS DISTRI CID <br /> LOCATION CODE <br /> 1 01 <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �v' W � ` +fWA CHECK if BILLING ADDRESS <br /> PX <br /> BUSINESS NAME S 1 PH N E <br /> suuI & " +(() S (tri« I� <br /> HOME or MAILING ADDR11S FAX # <br /> CITY p, STATE CrA ZIP Q ;p <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : qt �,! i L ly �� b'e � DATE : �� � (��' � <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT I L wa I }�t- ` it&C <br /> If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required 1 Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same tirp!4 s provided to me or <br /> my representative . �`i r /l/� <br /> TYPE OF SERVICE REQUESTED : S lV <br /> COMMENTS : AtIG <br /> -• / <br /> SA N j p � 1 2022 <br /> NEqA <br /> TND pAENo NTy <br /> RTC <br /> MEW <br /> ACCEPTED BY : J ?'/� � L� �D� ✓���� EMPLOYEE # : DATE: <br /> ASSIGNED TO : 00 EMPLOYEE # : DATE: l 22 <br /> Date Service Completed ( if already completed ) : SERVICE CODE : �� . ' �, P I E: <br /> Fee Amount: Amount Paid b Payment Date <br /> Payment Type Invoice # Check # 60412.5 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />