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�\ f�\a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST G <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `6 ,--\ <br /> OWNEBLOPERATOfi ^ <br /> ` CHECK if BILLING ADDRESS <br /> —_J <br /> S-V- 27 <br /> FACILITY NAME <br /> SITE ADDRESS 1 �axw>—)"x- \CU`-} <br /> Street Number Direction Street Name l_ I `C Zip Code <br /> HOME or MAILING ADDRESS (1f Different froomm(Site Address) <br /> C� 1 1 Street Number Street Name <br /> CITY STAT ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#Z EXT- 1303 DISTRICT LOCATION CODE <br /> ( } X81 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> PJ <br /> 1 i <br /> HOME or MAILING ADDRESS FAX# <br /> ct �Tl ( ) <br /> CITY STM 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 /> 1 also certify that I have prepared this application and that the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standarcds,STATE and FEDERAt,.•I" s, l <br /> APPLICANT'S SIGNATURE: DATE: a2,1 Z !Z "Z D 2� <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR NAGER ❑ OTTIER AUTHORIZED AGENT❑ <br /> !f APPLICANT is not the BILLING PA T- 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 availableat the same time it is <br /> provided to me or my representative. ^Y <br /> TYPE OF SERVICE REQUESTED: r'i�IV <br /> COMMENTS: P <br /> c [ y 2020 <br /> 8ANROUiN CpLN <br /> N rl�1 Dny <br /> ;per Af NT <br /> ACCEPTED BY: -1 �r �t EMPLOYEE M DATE:�1 <br /> ASSIGNED TO: \ V EMPLOYEE#: DATE:2 <br /> Date Service Completed (if already completed): SERVICE COCE: P f E: <br /> Fee Amount: 1`1 ov Amount Paid a Payment Date 2 2 y 2 Q <br /> Payment Type Invoice# I_Check# Received By: <br /> EHD 48-C2-025 I fJ� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ���"'CCC <br />