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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 I OPERATOR n <br /> A A 1 I CHECK if BILL NG ADDRESS <br /> FACILITY NAME iA- A b �8 e, ma2lL"- <br /> SITE ADDRESS <br /> Street Number I Dre on Street Name city zip Code <br /> HOME or MAILING ADDRESS (I Differ nt from SheAddress <br /> I !1t Ah 0. Street Number 54ee1 Name <br /> crrYL� STA zip <br /> PHONE#1 �>(�' EXT. APN# LAND USE APPLICATION# <br /> I�0?) loRk-9879 <br /> PHONERE><r. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK N BILLING ADDRESS <br /> I <br /> BUSINESS NAME PHONE# INT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CrrY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge dial 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,S TE and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O 'RA /MANAGER OTHER AUTHORIZED AGENT 11 <br /> IfAPPLIC4AT is not the B/LL/NG PARTY proof of authorization to sign is required Title <br /> ,,XTHORIZATION 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 available and at the same time it is <br /> 1),o%ided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C0NSv. 1pe c�,–; u-I RtC.. rf`/PAi <br /> COMMENTS: K•- I i�O <br /> M4R 3 V <br /> 84 IV jo <br /> y xl jrbN p Fcoo <br /> A <br /> ACCEPTED BY: EMPLOYEE DATE: Nj <br /> ASSIGNED TO: ( .e S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Vb 1 PIE: � b02 <br /> Fee Amount: IS -2 — Amount Pai Payment Date 3 <br /> Fayment Type Invoice# Check# 11115"Jl Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/21103 <br />