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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 0 0 0 0 qo N 0 0�S q�-LL <br /> OWNE�R/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME i ' <br /> SITE ADDRESS <br /> Street Number Direction I Street Name M nCl� C OI �de <br /> ' HOME or MAILING ADDRESS (if Different from Site Address) �>1 L ti,",C4- <br /> Street <br /> 4Street Number Street Name <br /> \, CITY STATE ZIP <br /> vt. -60.VnA f C 0 Ct <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> (/xt=91 ZZl Z( 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> l <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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 law <br /> APPLICANT'S SIGNATURE: DATE: /U=. Z -? Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 at the same time it is <br /> provided to me or my representative. D <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SAN"OV U 1 2022 <br /> NVIRONM Co <br /> Nti1ENTAL <br /> DE►'ARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Y I EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q ( ' P/E: ' O� <br /> Fee Amount: I GJ Amount Paid Payment Date [ 22— <br /> Payment <br /> 2Payment Type vl Invoice# _t6cc'k• Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />