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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />k�z\ <br />0 <br />FACILITY ID # <br />HOM r,1MAILI. G ADMN4`� �`�FAX <br />SERVICE REQUEST # <br />S R©0$4� 1q <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME �—\0",i 0 <br />�Jom <br />EMPLOYEE #: <br />SITE ADDRESS �)c <br />Street Number <br />E <br />Direction <br />�C� �5 �ll <br />V" ' 1 l Street Name <br />FYf �h C n)p <br />City <br />GK'S 0-31 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Fee Amount:�� <br />Street Name <br />CITY <br />Payment Date / 2 <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BOS DISTRICT / <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR \ 11 I i!. I, 1 i CHECK if BILLING ADDRESS❑ � V <br />l <br />BUSINESS NAME <br />P q 11 EXT. <br />HOM r,1MAILI. G ADMN4`� �`�FAX <br /># <br />( ) <br />CITY Y\ 11 Y� M P STATE r j1 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, STATES and FEDERAL laws.rA Y'6 <br />APPLICANT'S SIGNATURE: (t" 1 � " L r DATE: <br />PROPERTY / BUSINESS OWNERRI OPERATOR/ MANAGER ❑ 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 t0 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:IVL V) r <br />COMMENTS: / o l e �` C Iii r <br />n� - <br />GY►�_ CW i G < S <br />�D <br />I <br />o ?9 2021 <br />F� qQU/N <br />ACCEPTED BY: V I, <br />VVV <br />EMPLOYEE #: <br />DATE: /G /t1jjT <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: O zU <br />Date Service Com leted (if already completed): <br />SERVICE CODE: <br />P f E: <br />Fee Amount:�� <br />Amount <br />Paid <br />Payment Date / 2 <br />Payment TypeInvoice <br /># <br />Check # l <br />Rec ived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />