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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business PropertyFACILITY ID# SERVICE REQUEST# <br /> `) f�00D <br /> OWNER/OPERATOR <br /> jo-✓ [ r� CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME J U� �So <br /> J lL ( V `C-!x''fcC <br /> SITE ADDRESS 5 fuly O� <br /> Street Number Direction Street Name f'� Cit ZI Code <br /> HOME or,MAJl,I1�G Aoa ESS (Ifiplfff e am Site Address) <br /> Street Numbe= Street Name <br /> CITY � / � STATE ZIP Cry /r1 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# �J!✓( C/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> RECtUESTOR t-JU <br /> G CHECK if BILLING ADDRESS <br /> BUSINESS NAME x QZ 0 ~ 061 PHONE# ! EXr' <br /> HOME Or MAILING ADDRESS�� FAX# <br /> { } <br /> CITY G / 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 1 have prepared this application and thaa{ e work t foTmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERA f 'J <br /> APPLICANT'S SIGNATURE: DATE: / (� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER THER AUTHORIZED AGENT❑ <br /> 1fAPPLiCANT is not the BILLING PARTY,proof of authorization to sigh 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. <br /> TYPE OF SERVICE REQUESTED: G M PAYMENT <br /> COMMENTS: <br /> JAN 0 6 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P!E: <br /> Fee Amount: DO I Amount Paid 1 � Payment Date <br /> Payment Type Invoice# Chedfc Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />