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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��ollb/I� <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> \f S <br /> FACILITY NAME <br /> SITE ADDRESS {f <br /> S ` 7 y <br /> Street Number Direction SC-C rCtNam� ` citya. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number C) 6 Street Name <br /> CITY ZIPS v I L� rA? S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 4v3) S o I <br /> PHONE#2 ExT. 605 DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR_ 1 <br /> `_ I 1 c ' 0. I • .�� , � _ HECK if BILLING ADDRESS❑ <br /> BUSINESS NAME y / PHONE# cc ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 5 Li j>L)YJ <br /> STATE ,1' 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 SIGNATURE j2'— DATE: C IW2-0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER EP OTHER AUTHORIZED AGENT❑ <br /> If APPLiCANTis 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. <br /> TYPE OF SERVICE REQUESTED: 1^ C M <br /> COMMENTS: CUVI <br /> �' AUG 19 2020 <br /> AN joAQUENVIROrN COUvry <br /> EALTH pEPARTTAL <br /> ACCEPTED BY: I n rG EMPLOYEE#: may, / � DATE: <br /> -� i <br /> ASSIGNED TO: WWW ` EMPLOYEE#: / l �/ DATE: I�' <br /> Date Service Completed (if already completed):, j� SERVICE CODE: 1 P 1 E: <br /> Fee Amount: 2 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD48-02-025 COKI W l 112��"! "J��-�' SR FORM(Golden Rod) <br /> REVISED 11/17/2003 U <br />