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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE=RVICE REQUEST# <br /> OWNER/OPERATOR <br /> j l CHECK If BILLING ADDRESS <br /> FACILITY 14AME fl_ h 17 <br /> S)TE ADDRESS <br /> Street Number Dl ectlon Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 lwxT. APN# LAND USE APPLICATION# <br /> ( ;x,41 ^ ��� o�+Hp30gt� <br /> PHONE#2 ExT. BOS DISTRICT LOCATI N CODE <br /> c r 002 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> � CHECK If BILLING AODRESSE] <br /> BUSINESS NAME [ f1 } � RKQNE# EXT. <br /> HOME Or MAILING ADDRESS tf�) FAX# <br /> Ci 71_ ( 1 <br /> CITYSTATEVo� Zip Elsa, <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 TF and FEDERAL laws, r c� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B11.LING 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 my representative. <br /> TYPE OF SERVICE REQUESTED: 'Al <br /> COMMENTS: f yf�h <br /> SAN Ja 1 0 z 2020 <br /> SAN JOAQLI/Al <br /> 11�AC7N pip ENTAD 1Y <br /> ACCEPTED BY: I A EMPLOYEE#: DATE: <br /> ASSIGNED TO: C� EMPLOYEE#: DATE: <br /> Data Service Completed (if already completed): SERVICE CODE: PIE: 02 <br /> Fee Amount: I�Z Amount Paid �6 Payment Date ID R 0v <br /> Payment Type L} Invoice# Check# Received By: <br /> EHD 48-02-025 _ �Mv� <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 11%- to Z <br />