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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s oot oo�7�a SKoo-/-:3:,?ay <br /> OWNER/OPERATOR <br /> CHECK it BILLING ADDRESS� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> SG -,NaA <br /> p Street Number Direction � "W/1city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SUeet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ea'' APN# LAND USE APPLICATION# <br /> (za» 952--/ ;�73 S- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (2c9) L G <br /> i i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 9^ Si WG CHECK If BILLING ADDRESS� <br /> BUSINESS NAME PHONE# ExT. <br /> C ti✓t'�iIZ� l ✓toad (1-7) 99Z /�TI� <br /> HOME or MAILING ADDRESS FAX# <br /> S-& CN C N R If A- r r ( ) <br /> CITY 570 CSTATE cll+ ZIP c�SwC <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project speclflc ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this appli tion and at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, Sr and FE RAL la� <br /> APPLICANT'S SIGNATURE: G� DATE: Z/llf <br /> PROPERTY I BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a$ soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if alreatl completetlj: SERVICE CODE: PIE. <br /> Fee Amount: ,C)�) Amount Paid Payment Date <br /> Payment Type Invoice# Check# P Received By: <br /> RECE��E/� <br /> oT/D 48- 2 025 SEP•$5 201 FORM(Golden Rod) <br /> SAN�OAQUfIV C <br /> aE,gL Dap,Aq <br />