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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 50, <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME f r <br /> SITE ADDRESS <br /> Li�'ko� tr <br /> Street Number Direction eat Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Ol Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) C- L <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR .,— CHECK If BILLING ADDRESS <br /> cc<-t Z <br /> BUSINESS NAME 4 PHONE# EXT. <br /> J 6:)-�) T yALIS � k :.. 6 9 U <br /> HOME or MAILING ADDRESS FAX# <br /> r' ( ) 0'S:�-<{ J <br /> CITY J 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 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. <br /> APPLICANT'S SIGNATURE: r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M 'AGER ❑ OTHER AUTHORIZED AGENT 11If APPLICANT is note 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 <br /> my representative. <br /> TYPE 0 � <br /> COMMEI�i�t C <br /> MAy 2 g 2020 <br /> �OVNN <br /> SA EN�R EP ENSMENj <br /> ACCEP Y: EMPLOYEE#: DATE: <br /> c / <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:D <br /> Fee Amount: Amount Paid �S� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />