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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �?SERVICE REQUEST# <br /> SI`W DOX <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS //�� t' <br /> X If4We�Number Direction Street Name" y� City <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATS ZIP 9sz <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> 17-01f I &i3--z z-& -3Z-3' <br /> PHONE#2 EXT. BOS DISTRICT —4:—TOC ATIO <br /> LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> —1,W ) s <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY A! 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 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: JDATE:Z l -- <br /> Zl- <br /> PROPERTY/BUSINESS OWNER❑ OPE O / ANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign 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: <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> APR 2 7 2021 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: ENVIRX r <br /> HEALT <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): I -TSERVICE CODE: P/E: <br /> Fee Amount: 16 Amount Paid Payment DateOwl <br /> Payment Type v Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />