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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ( ` 7 L� <br /> -�1� 1,_ ?j r-- <br /> OWNER OPERATOR I ���r <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAM 2 J <br /> SITE ADDRESS hil- <br /> 1 <br /> Street Number Direction et Namei `. Code <br /> HOME Or MAILING APPRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �TE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (;4 <br /> 4 � �L, <br /> PHO E#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( It 4) 7 (> ` t% <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> � � CHECK If BILLING ADDRESS <br /> EXT. <br /> BUSINESS NAM r 1 PH�{JE %1`1_�]�7�" <br /> HOME Or�t41LIIN-�ADARESS ( l/ ( ) -L? �I ``?�, <br /> CITY �� �l'/,1�� STAT <br /> BILLING AC NOWLEDGEMENT: 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 busines s I e i ed on this form. <br /> I also certify that I have prepared this applica ion that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta ards, TATE d FE L laws. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER PERATOR/MA A ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLRTY roof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INF N: 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 att�e Same time it is <br /> provided to me or my representative. AY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> JUL 0 3 2020 <br /> SAN JOgQUIN C0 <br /> U7 <br /> ENVIRONM <br /> CN <br /> HEALTH DepARTMENTl' <br /> ACCEPTED BY: ¢� EMPLOYEE#: DATE: <br /> ASSIGNED TO: rv� EMPLOYEE#: DATE: Z <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P/E: <br /> Fee Amount: l 2 Amount Pai — UJ> Payment Date ` —//, � Z� <br /> Payment Type Invoice# Check# 2.23 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />