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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> �sr iL SP ) 0�S % () <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> d dCE- <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> P0• I�0/l Street Number Street Name <br /> CITY STATE ZIP <br /> 2 C i!AmP CA f 5A31 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> wv f ) �82- (P 3 /00-/3 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> =1( ) C. <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mn CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> o A fW 82-6 6 <br /> HOME or MAILING ADDRESS FAX# <br /> If, 510 yr 3 40 ( ) <br /> CITY me14 Ln STATE CA 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 /> 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, ST: _a d FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: DATE: /2— <br /> PROPERT)'/BI SINESS OWNER12 OPERATOR/MANAGER ❑ OTIJER At TtIoRtZED AGENT❑ <br /> If APPI,R'd,NT 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 the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL_HEAL.TFI 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: 3.011- su t,)rA&/L/ T A,1/7;eA7E LOAD t N 57_aP11=5 E✓/E� <br /> COMMENTS: <br /> ECEIVED <br /> DEC 2 3 2019 <br /> A IRQUIN COON <br /> 11CNMEN TY <br /> ACCEPTED BY: EMPLOYEE#: DATE: M T <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> r% <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: L).v <br /> Fee Amount: Amount Paid lX Payment Date <br /> Payment Type Invoice# Check# l O Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />