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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> l "f MPrK A0000 al S V 5q ;L� <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME D I tju M A {iM� <br /> SITE ADDRESS I o D ` t CNI I >q V E t Cf} � :3 <br /> Street Number Direction Street Name Cit 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � v S' S Iv 6 E] <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME . 1 M �' PHONE # 5 � i 1 O O EXT. <br /> J ' v u i o ) J `i Q <br /> HOME or MAILING ADDRESSO O 1 OS � � I /� V FAX # <br /> l n ( ) <br /> CITY CAMV47E C A STATE ZIP S33 <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 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 laws . <br /> APPLICANT ' S SIGNATURE : _(� DATE : o <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization t0 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. /— 1 w <br /> TYPE OF SERVICE REQUESTED : �- G -� C(} Nr S �1 L T A T / fJ # �Wy <br /> COMMENTS : RieCSOVE® <br /> OCC* 12 2021 <br /> SAN JOAQU/N <br /> FiEq�H DEV EN7q� N <br /> ACCEPTED BY : ` , EMPLOYEE # : DATE : r l) 2 I ZQ Z <br /> ASSIGNED TO : IJ V EMPLOYEE # : 11 DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE : 1 P / E : 3 <br /> Fee Am . 5 oun Amount Paid ` 2 r Payment D11ate Ip1 v2 Z� <br /> Payment Type Invoice # the ti 330w::+8C> Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br />