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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# � SERVICE REq��o <br /> 6URE <br /> OWNER/OPERATOR <br /> r CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS `�''✓J um _\ _ �/ <br /> Street Number Oirectlo Street Name I ` zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Addr ss) <br /> Street Number Street Name <br /> CITY S„ STATE C•/ , ZIP <br /> PHONE#1 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 /> (0ca—mg <br /> � <br /> HOME Or MAILING ADDRESSJ FAX# <br /> r "'4' ( ) <br /> CITY Sh&b-kh <br /> 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 /> 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, ST T aqd RAL la S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ,--PROPERTY/BUSINESS OWNER42y ATOR/MANA ER ❑ OTHER AUTHORIZED AGENT r3 V,4-, <br /> If APPLICANT is not the BILLING PARTY proof ofauthorization 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. <br /> TYPE OF SERVICE REQUESTED: O C (�' PAYMENT <br /> COMMENTS: KtCEIVED <br /> 4 U 3 1 2020 <br /> SAEJOAQUIN <br /> TM <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: g <br /> ASSIGNED TO: EMPLOYEE#: Z. DATE: <br /> Date Service Completed (if already completed): SERVICECODE: v D I E: 1(pC)3 <br /> Fee Amoun 5 a-40 Amount Paid S Z Payment Date 3/ -Zio 2,7;) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />