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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `Nu i L �P � <br /> OWNER/OPERATOR <br /> 6 <br /> n,4 Z /7O/C/V n ,// /�1 —14-C <br /> CHECK If BILLING ADDRESS� <br /> FACILITY NAME CC <br /> SITE ADDRESS 2 7 5' /[d�0 <br /> Street Number Direction Street Name d1tv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STAT ZIP <br /> S ZE A/r �A S7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 0 6 -2 5-0 —nor)-/r;- <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 1-fYZrt� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO E# EXT. <br /> on( GILT�� ( 0 —/,�S <br /> HOME or MAILING )DRESS FAx# <br /> 130 3 c ) <br /> CITY �' Z- STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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 a cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T TE and F L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ 1,ization <br /> ER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of aud, 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. A, <br /> TYPE OF SERVICE REQUESTED: FV I�W Ill r <br /> COMMENTS: <br /> JON 3 2021 <br /> SAN j04Q <br /> HEAL J1 N&fEIV7AN� <br /> DEAR r L <br /> ACCEPTED BY: �—/)z Z L EMPLOYEE#: DATE: G /3��a <br /> ASSIGNED TO: A I EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: l �a <br /> Fee Amount: ' (� Amount Paid Payment Date l3 22 <br /> Payment Type Invoice# Check# � 0` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />