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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sorg-L c: 5R008 I a 54 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME � Q <br /> SITE ADDRESS v V -S 0-S E(V VnnVI T(�I, (-•/ C P 9130y <br /> \-1 k4 'A \Iistreet s6t€' <br /> SNumber DirectionStreet Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#f EXT. APN# C? j 1 LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ) <br /> S, (ACHECK If BILLING ADDRESS <br /> S\,) IViV <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 1 7, <br /> CITY J� I �TI�TE 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. i q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT"K <br /> If APPL/CANT 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. <br /> TYPE OF SERVICE REQUESTED: 0- S ilk t l 9K III, <br /> D <br /> COMMENTS: <br /> OCT 0 9 2019 OCT 0 9 019 <br /> ENVIRONMENTAL HEALT JOAQUIN C UNTY <br /> PERMIT/SERVICES ENVIRONMENTAL <br /> / HEALTH DEPAR MENT <br /> ACCEPTED BY: EMPLOYEE#: io / DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: ! f t <br /> Date Service Completed (ifal ady completed): SERVICE CODE: PIE: j <br /> Fee Amount: C; Y - Amount Paid (� g— Payment Date L' <br /> Payment Type Invoice# Check# rj Received B : <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />