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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sp ow2355 <br /> OWNER/OP,ERATOR <br /> G/ CHECK It BILLING ADDRESS <br /> FACILITY AMErad <br /> SITE ADDRESS a <br /> 3 0 Street Number I Direction E e b eiStreEtS to CI ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) u nter• S <br /> /225? Sheet Number Street Name <br /> CITY STATE ZIP ?5-20 <br /> -20 e5 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (Zog) 3- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME ' _ PHONE Eu. <br /> Zo <br /> HOME or MAILING ADDR S FAX# <br /> ( ) <br /> CITY f C e STATEcc� ZIP �O C <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 /> 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 laww/s. <br /> APPLICANT'S SIGNATURE: �k2a DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA ❑ OTHER AUTHORIZED AGENT <br /> I,fAPPL/CANT is not the BILLING PARTY Proof of authorization 10 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 t0 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. Aft <br /> TYPE OF SERVICE REQUESTED: µo I eRw— Ery <br /> COMMENTS: <br /> UL 2 2 2020 <br /> SAN JOAQUENVIRIN CO <br /> LIN <br /> HEAL-T4p ARTMENT <br /> ACCEPTED BY: VU�� EMPLOYEE#: �Lo DATE: <br /> ASSIGNED TO: EMPLOYEE M Z DATE: �( <br /> Date Service Completed (If already completed): SERVICE CODE:✓✓✓ P I E: <br /> Fee Amount: I '� Amount Paid Ir5 a Payment Date ZZ 2—O <br /> Payment Type Invoice# Ghec Received By�y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />