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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST# <br /> Q.:s sft0t 'ti <br /> OWNER I OPERATOR�Rm <br /> tX. CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS tr � <br /> S eet Num er Direction Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Strae[Numeer Street Name <br /> CITY STATE ZIP <br /> PHONE#t EiT. APN# LAND USE APPLICATION# <br /> ( I <br /> PHONE#2 Eir. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR �y <br /> REQU ESTOR CHECK If BILLING ADDRESSEI <br /> BUSINESS NAMEPHDNE# E:r' <br /> �2 KDc t S Sff u -rt cL <br /> HOME Of MAILING AD RESS r I FAX# <br /> CITY C! as� /1 q �I a, 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 'CC �Ef(_//_��t(�.[rc, <br /> If APPLICANT Is not the BILLING PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: V � t <br /> AUG 2 5 2017 <br /> ENVIRONMENTAL HEALTH <br /> ACCEPTED BY: EM DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): -SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />