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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properbt FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR / <br /> CHECK IT BILLING ADDRESS <br /> FACILITY NAME C /{C a 111 <br /> SHE ADORES! <br /> S[reat Number DirectionI �V I Street Na a i Zip Code <br /> HOME or MAIIL59 ADDRESS (If Different from <br /> SIt Ad�Id_resssJ <br /> vvV _ Street Number Street Name <br /> CITY STATE ZIP <br /> P NE#1 En. APN# LAND USE APPUCAT10N# <br /> ( 6A 3 � S� �i��le ' <br /> PHONE#Y Ev. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR '�� <br /> 1 I 011A �(�7,� CHECK If BILLING ADDRESS <br /> BUSINESS NAME �� P LLL ��` PH NE# , Err. <br /> C 7 <br /> HOME or MAILING ADDRESS /� FAX# <br /> �*—P"h7 d''7 /J l ( 1 <br /> CIN nye O�� STATE /� ZIP V-s--3 <br /> BILLING ACKNOWLEDGEM—ENT: 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 a done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /L-,- <br /> 2� C7 hl/ <br /> PROPERTY/BUSINEss OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L r71�. <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 avail at the same time it is <br /> provided to me or my representative. <br /> Tf <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: DEC 10 2019 <br /> H;W7W 08, rtr <br /> WRONJOAQUME OUNTy <br /> Amrk <br /> ACCEPTED BY: (� EMPLOYEE#: DATE: \2\ill <br /> ASSIGNED TO: v EMPLOYEE#: DATE: N�A\u \q <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: 1 u V l <br /> Fee Amount: Amount Paid Payment Date O <br /> Payment Type Invoice# Check# Received B : <br /> EHD (/ �V LLl ` ` 5b� SR FORM(Golden Rod) <br /> REVISEDSED 1111 11/17/2003 <br />