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SAN JOAQUIN COUNTY ENVIRONMENTAL HE, ALTH DEPARTMENT <br /> SEILVICE REQUEST <br /> Type of Business or Property FACILITY 1D # SERVICE REQUEST # <br /> Rvf) 81 ssl <br /> OWNER / OPERATOR <br /> CNECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS (J�J, �] <br /> StroatNumber D tion �"'� SiAot a � LV fit <br /> zl Co`d�e�( <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Numbor Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXL APN # LAND USE APPLICATION # <br /> 139 ) k B L4 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> H ME or MAILING A DRES 1 FAX # r <br /> yl L <br /> CITY STATE ZIPCPU <br /> BILLING ACHNOWLEDGE' MENT: I, the undersigned property or business owner, operator or authorized agent of sarne, <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, Standar ATE and IiED . laws, <br /> APPLICANT ' S SIGNATURE : � � DAT) 1 A 1 A 0, [)'r <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTIJFR AUTHORIZEII AGENT � )" ! C, <br /> If APPLICrINT is not the BILLINGYARTY, proof of authorization to sigh 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 HEAL'CH DEPARTMENT as soon as it is available and at the pi time itis <br /> provided to Ine or my representative, Y <br /> TYPE OF SERVICE REQUESTED : I , _ ) . L4� c 11 <br /> i <br /> COMMENTS: DC^ D <br /> SAN ,0 2023 <br /> NF40) �p p�6A/C�N Y <br /> RTMEN <br /> ACCEPTED BY: EMPLOYEE #: , DATE: <br /> ASSIGNED TO ; EMPLOYEE # : . , r DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: PIE : <br /> , <br /> Fee Amount: ;t, t Amount Paid 11 14 2 Payment Data <br /> payment Type vl S � Invoice # Check # I ? 3 Gd Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />