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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Al Z "tZVJE-7- A 0061 70 2 5900 7 <br /> OWNER/OPERATOR <br /> .T0 N G- d P V-- CHECK if BILLING ADDRESS <br /> FACILITY NAME co CN ` �0 �/ <br /> SITE ADDRESS � �-�D <br /> Street Number Direction Street Name C t 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 /> (0400 90( 0� 6-- 'p-1,)o . <br /> PHONE#2 EXT. BOS DISTRICTCATION CODE <br /> T <br /> ( ) (.t Eu <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( 'I b) 3o I - A 6 " <br /> HOME or MAILING ADDRESS FAX# <br /> o Z61(Z ( ) <br /> CITY DO 9 N9 I STATE ZIP /Ji �(1 / <br /> BILLING ACKNOWLEDGEMENT: 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 be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE andFEDERALlaws. <br /> APPLICANT'S SIGNATURE: yy C DATE: 1y / 2- 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT K 1-7?F---L <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titleer�^^ ENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property loc+a ppgCEJVED <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sites�essment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sate a 2021 <br /> provided to me or my representative. SAN <br /> ,l COUNTY <br /> TYPE OF SERVICE REQUESTED: I� C�1 ENVIRONM NTAL <br /> COMMENTS: ' PARTMENT <br /> CASE-S AT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: N EMPLOYEE#: DATE: l! C W <br /> Date Service Completed (if already completed): SERVICE CODE:�)ZzJ P/E: 'I�D <br /> Fee Amount: S () Amount Paid Payment Date c <br /> Payment Type Invoice# Check# _ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />