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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />FAX# <br />CITY STATE ZIP <br />o� �� <br />s10-00( 40S <br />OWNER I OPERATOR I Q �/ inn I i y <br />�/ myVt V r' Y <br />CHECK If BILLING ADDRESS <br />EMPLOYEE#: /,)C- <br />DATE <br />FACILITY NAME Soh w <br />already Completed): <br />SITE ADDRESS420,1 <br />✓Street_Nlumber <br />SERVICE CODE: 1 Q <br />C NWYYt yr.�lr <br />L-0 STL (!7 <br />sto (,{-"Y, <br />0[5-2-(0 <br />0 <br />Direction <br />Street Name <br />city <br />ZIP Cade <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />�A,o-o d U f <br />I <br />III I Z <br />Street Number <br />Street Name <br />CIT' td l,iY! V l-oV n <br />STATE G ZIP Cl` <br />SZ 1D <br />PHONE#1 En. <br />APN# <br />LAND USE APPLICATION# <br />(2,01) sli(--1,2.4q <br />EHD 48-02-025 <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK It BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT' <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY 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 appliFpation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,=EFEDERALws. <br />stPPLICANT'S SIGNATURE: DATE: 2— 2 0 Z <br />PROPERTY/ BUSINESS OWNER® OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ Ii EV <br />IfAPPLICANT is not the BILLING PARTY proof of authorization 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 atttf at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />sh <br />utL 2? 2021 <br />JOAQUIN <br />NAL 1 TY <br />ACCEPTED BY'. <br />Vl <br />EMPLOYEE M % () <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: /,)C- <br />DATE <br />Date Service Completed (if <br />already Completed): <br />SERVICE CODE: 1 Q <br />P / E: U2 <br />Fee Amount: <br />r�D2 - <br />0 <br />Amount Paid <br />(S �. �� <br />Payment Date <br />z <br />Payment Type <br />Invoice# <br />Check# ��loJ S 3 <br />Received y: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />�(4 I —1 2-Z- <br />