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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR v C ECK if BILLING ADDRESS ❑ <br /> doo <br /> FACILITY NAME <br /> SITE ADDRESS , <br /> Street Number Diroction Afteet Name SCK ' <br /> HOME or MAILING ADDRESS (If Different from Site Address ) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> ? (u (� L- <br /> PHONE #Z Exr• BOS DISTRICT LOCATION CODE <br /> ( ) 0717 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �" PHONE # Exr. <br /> HOME or MAILING ADDRESS - FAX # <br /> CITY `/P� v STATFG.' y+ .� ZIP y,� L <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 Or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 an , la �] <br /> APPLICANT' S SIGNATURE : DATE : '`� <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGEN140, �� <br /> If APPLICANT is not the BILLING 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 ttP"IMEINT <br /> site address ;hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment i r po <br /> t0 the SAN JOQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it is provide �rIVED <br /> my representative . <br /> AU 2021 <br /> TYPE OF SERVICE REQUESTED : <br /> %)AN JOAQUIN COUNTY <br /> COMMENTS ; - ENVIRONMENTAL <br /> d A� yl '2 bEALTH DEP RTMENT <br /> ACCEPTED BY ' ^ I ca t J !/ `J EMPLOYEE # : DATE : <br /> ASSIGNED TO : EMPLOYEE # : DATE: 0 / / >J <br /> bate Service iC///occCm' pplleted ( if already completed) : SERVICE CODE : f _ Gl� PI E : r� <br /> ' � <br /> Fee Amount : ' / t` O Amount Paid 5 Payment Date L� u <br /> Payment Type `� Invoice # Check # l V Received By : <br /> j ' II , <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />