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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />� n CHECK It BILLING ADDRESS <br />1 <br />BUSINESS NAME <br />FACILITY ID # <br />L) <br />SERVICE REQUEST # <br />�33 <br />Q <br />C o <br />CITY STATE ZIP <br />OWNER/OPE TOR <br />HEUNTY <br />ALTH DEpA NT <br />RBILLINGADDRESS❑ <br />FACILITY NAME <br />` <br />�� <br />EMPLOYEEM <br />DATE: <br />$READDRESS <br />R <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already Completed): <br />. SERVICE CGDE: 2 <br />14900 Street Number <br />Direction <br />W. Hwy 12 <br />Street Name <br />�� <br />Lodi <br />c <br />95242 J <br />4feMsor MAILING ADDRESS (If Different from Site Ad rase) <br />�4 <br />Check # /2—/2—S2,2- <br />Recelved By: <br />Street Numtar <br />et Name <br />CITYSTATE <br />ZIP <br />PHONE#i� _ ^ <br />rn. <br />APN0 <br />LAND USE APPLICATION# <br />PHONE#P <br />l 1 <br />Ex . <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQUESTO <br />� n CHECK It BILLING ADDRESS <br />1 <br />BUSINESS NAME <br />NE# Ev. <br />\ �\ <br />1h1�/ <br />HOMEor MAlu ADDRESS <br />FAX# <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1,(&e 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 prep,,v*d-MTFFp-pTtcskion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance CodeseeStandards, STATF)and FEDERAL lawf.- _ <br />APPLICANT'S SIGNATURE: --\ �(,a�iO�A\Q_� C/� hATr.. 1�—Z S -T, <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHERAUTHORIZED <br />/f APPLICAA'T is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 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. PAYne p a — <br />TYPE OF SERVICE REQUESTED: G y . G - S <br />EC <br />COMMENTS: <br />MAR 01 <br />2021 <br />SAN JOAQUIN CO <br />HEUNTY <br />ALTH DEpA NT <br />NT <br />ACCEPTEDBY: <br />�� <br />EMPLOYEEM <br />DATE: <br />ASSIGNED TO: <br />R <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already Completed): <br />. SERVICE CGDE: 2 <br />PIE: /(;()I <br />Fee Amount: <br />TJG — <br />Amount PallTi�(a <br />�� <br />Payment Date 3// Z� <br />Payment Typ <br />C <br />Invoice # <br />Check # /2—/2—S2,2- <br />Recelved By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 �� O 2 5 <br />