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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU ST# <br /> G�,� {®0`i0�F <br /> OWNER/OPERATOR <br /> / CHECK if BILLING ADDRESS <br /> L7 <br /> FACILITY NAM <br /> SITE ADDRESS Le w10 iq c- v(— <br /> T—'Zip <br /> 7J Z U <br /> ZY1-18 L-1 Street Number Direction Street Name Cit Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (zoo' ) IZ-0130 � G - v _'�, `3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (zoo ) 2 -D /36 <br /> 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> � C..U'I-. CHECK If BILLING ADDRESS <br /> BUSINESS NAME , PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this applic ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA !2�� <br /> s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /(APPLICANT 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 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: <br /> COMMENTS: <br /> DEC 16 2019 <br /> SAN JOAQUIN COUNTY <br /> H�TN DEP ENTAL <br /> ARTME <br /> ACCEPTED BY: EMPLOYEE M DATE: / I <br /> ASSIGNED TO: EMPLOYEE M DATE:l <br /> Date Service Completed (if already completed): SERVICE CODE: L� % E: <br /> v <br /> Fee Amount: ti Amount Paid .�� Payment Date a j <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />