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'neem F (2- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# // SERVICE REQUEST# <br /> I W-7 <br /> t <br /> OWNER/OPERATOR <br /> 14, /���' �1 P� ' U l�`L CHECK If BILLING ADDRESSO <br /> FACILITYNAME I /�l�i <br /> SITE ADDRESS <br /> Street Number Direction 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 /> 50cit-fro <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I / <br /> j C K I r o ✓1_� CHECK If BILLING ADDRESS El <br /> BUSINESS NAME n PHONE# EXT. <br /> lib* Laos _} -rte I � <br /> HOME or MAILING ADDRESS S/ FAX# <br /> CITY c �)V) STATE C/4 <br /> ZIP 1?f 1/1 <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. J ` <br /> APPLICANT'S SIGNATURE: DATE: <br /> —T <br /> PROPERTY/BUSINESS OWNEOPERATOR/MANAGER ❑ OTHER AUTIIORIZED 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 the or my representative. <br /> TYPE OF SERVICE REQUESTED: "COp k (�1 cjl_ <br /> nkkr� <br /> COMMENTS: IV ® <br /> r <br /> Ne�,J -T11,0 L OCT o `G <br /> 2021 <br /> 5 <br /> Sq JO,4 <br /> HE�NVI�p VM ENTq N7'Y <br /> ACCEPTED BY: \ EMPLOYEE M DATE: I Z� <br /> ASSIGNED TO: J' CG EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: , i P/E: <br /> Fee Amount: LAmount Pa L�s Payment Date <br /> i <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />