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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /'-Ao b 20,)s SV <br /> Q, oSu 3--4-0 <br /> OWNER/OPERATOR i <br /> /�!�l ��A?Z� Gr 1'id ['f'1'1 Z/� CHECK If BILLING ADDRESS <br /> FACILITY NAMEC <br /> L L,0_ %wC v r <br /> SITE ADDRESS f(' <br /> S <br /> 6tUUYtQ d��• �"tc C�<T'k �S�/ <br /> Street Number Direction KI, City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#i EXT. APN# LAND USE APPLICATION# <br /> PHONIER EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> i <br /> CONTRACTOR / SERVICE REQUESTOR j <br /> REQUESTOR <br /> P(dI't � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> kL S'wl -,� •5v - / <br /> HOME Or MAILING ADDRPS� �� ! FAX# ) <br /> CITY Sf�xh( STATE /'d ZIP qS��JC�/ <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE dgFEDERAL law <br /> APPLICANT'S SIGNATURE: DATE: /ti - <br /> PROPERTY/BUSINESS OWNER❑ OP�RATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If fI PPLICANT is not the ILLING 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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and,��tj,$,�s�ple the it is <br /> provided to me or my representative. F' ��(IYIIC <br /> TYPE OF SERVICE REQUESTED: OCTKECEMUCOMMENTS: C19 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Ap / } EMPLOYEE#: DATE: (ClZl <br /> ASSIGNED TO: C V EMPLOYEE#: DATE: I 19 l <br /> Date Service Completed (if already completed): SERVICE CODE:1 . PIE: -1 <br /> Fee Amount: G Amount Paid ( SZ — Payment Date <br /> Payment Type LS Invoice# Cft96# �j q ! O q72,-q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />