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SAN JOAQUItN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME PHONE# Em HOME Or MAILING ADDRESS FACILITY ID # CITY STATE ZIP SERVICE REQUEST # h SRO N 00 4 7 - �ACTyOFpgR 7 OWNER OPERATOR C—\ /�� ►" � -� CHECK If BILLING ADDRESS rn� f � � C- �i \ Date Service Completed (if already completed): FACILITY AME PIE: 1 I ' C(C?�"� �W l Amount PA"L>PA" Payment Date S Payment Type oYY\ 1 �. SITE ADDRESS 1 9-Q) Received By: C� 1 \ \ �C� � �\}'e 7Iro\C'Vq 5 3 I Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 31412- rv\-; f2/1- P�y� Street Number Street Name CITU SITTTO V^�P 2 PHONE #1 Exr• APN # LAND USE APPLICATION # (2U1) -114 9 PHONE G En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS -O\1 BUSINESS NAME PHONE# Em HOME Or MAILING ADDRESS FAx # CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my businessas d on this form. I also certify that I have prepared this ap H t tha the work to be performed will be done in accordance with all SAN JoAQUIN COUNTY Ordinance Codes, Standards, ATE E laws. (, APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER❑ A AGER ❑ OTHER AUTHORIZED AGENT ❑ ITAPPLICANT is not the BILLING PAR rt roof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Aw . _ TYPE OF SERVICE REQUESTED: C COMMENTS:Atoll O �® SF do 8 2021 h SRO N 00 4 7 - �ACTyOFpgR 7 ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: S DATE: Date Service Completed (if already completed): SERVICE CODE: ob1 PIE: Fee Amount: 1'UU Amount PA"L>PA" Payment Date S Payment Type Invoice # Check # / Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) ) S0 G