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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rvc� S <br /> OWNER/OPERATOR <br /> JC�L1iUC CHECK If BILLING ADDRESS <br /> FACILITY N/TE h :d--c3' <br /> a <br /> SITE ADDRESS <br /> l7 <br /> � , o7dmticr Direction Street Name / 9( W.X <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE_ ZIP _ <br /> (r4— <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> V62) - 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.T. <br /> Ti,20- l <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY _ I STATE G .f I ZIP 9S an <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 t e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , TA and aws 1 <br /> APPLICANT'S SIGNATURE: !Z: DATE; ,3 <br /> PROPERTY/BUSINESS OWNER OPERAT /MANAGER ❑ UTHORIZED 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 the or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 1�1ENT <br /> RECEIVED <br /> vxusiI i LIAR 0 7 2022 <br /> ACCEPTED BY: VVtL�`e-e EMPLOYEE#: E ENTAL <br /> ASSIGNED To: "�7 EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: GI�I P/E: LU "I <br /> Fee Amount: 14 <br /> I •/) Amount Paid I S-Z Payment Date <br /> Payment Type C G I Invoice# Check# ✓7 Received By: <br /> EHD 48-02-025 SR RM(Golden Rod) <br /> REVISED 11/17/2003 <br /> f 4 l(a0 2t-I 5- <br />