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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ~ Type of Business or Property FACILITY ID# SERVICE REQUEST# ( <br /> At4.� ,� B � ,, <br /> RtPAiook 0D l01 Cl ` 10 <br /> OWNER i OPERATOR <br /> 1 ` sc) peje CHECK If BILLING ADDRESS El <br /> je- <br /> FACILITY NAME/ ('_f-�L[)[�•�S ��j� �_/ 1� <br /> SITE ADDRESS l In d <br /> rection ` tL `Tjo�si�+' Irk' 0 <br /> / D�Y StreetNumber DiStreet Name city Code <br /> HOME Or MAILING ADDREESSS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR67. <br /> G� cA 4., / CHECK If BILLING ADDRESS <br /> BUSINESS NAME ,/C/� PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE 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 or <br /> 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, TE nd JFRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERAT /M G OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PA proof of a orization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMAT When applica e, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release o any and all 11 <br /> ,geotechnical data and/or environmental/site assesAsment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEA�K DEPARTMENT as soon as it is available and at the same time it islided to me or <br /> my representative. I��YI <br /> TYPE OF SERVICE REQUESTED: F� <br /> COMMENTS: C9 <br /> 2018 <br /> y��o�'�FcCVN <br /> TV,p52 U2 Fp Mqt ry <br /> FNT <br /> ACCEPTED BY: r EMPLOYEE#: DATE: ���l CID <br /> ASSIGNED TO: I)k EMPLOYEE#: DATE: t IL/�)A b <br /> Date Service Completed (if already completed): SERVICE CODE:-}(,�{j (,(�j I PI E: <br /> Fee Amount: lS�,ZO Amount Pais �tJ Payment Date 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />