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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST �, Gj12 1-2 x(p <br /> Type of Business or Property L-1 rITA1 FACILITY ID# *-REQUEST# <br /> IEXJ 0 rZy u 6Z vOC n) - fTv r--A (D <br /> OWNER/OPERATOR <br /> I r Jq � b t/ ��b 1 U CHECK If BILLING ADDRESS <br /> �In <br /> FACILITY NAME L)( U 1/�L- `n JD n A ` 'AA-(2—"�J- <br /> SITE ADDRESS �� ��cin_ y` le S�� <br /> Street Num r Di ection treat Name Cit Zi Cod <br /> HOME or MAILING ADDRESS (if Differentfr Am Site Address) <br /> gqoI v � r`� Street Number Street Name <br /> CITY 9 Co-S'A ATE ZIP <br /> /l1 Zi7 <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 app <br /> o and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TA F ERA S. <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNER❑ PE ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPLICANT is not the BILLI G 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. MAY. MENT <br /> TYPE OF SERVICE REQUESTED: {�lI ('f,()ju ( s fRECEIVED <br /> COMMENTS: <br /> Ftf~R 13 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: y- EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 ,✓s ( T'.—� EMPLOYEE#: DATE: Z <br /> L-v�. J <br /> Date Service Completed (if already completed): SERVICE CODE: O P I E: Q <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />