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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2- <br /> wLIlls <br /> OWNER/OPERATOR <br /> b7 CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> -T-0c, <br /> ,^ <br /> SITE ADDRESS Q vim; 1 1 """(—� S 34`0 <br /> Street Number Direction Street Name \ Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nii�� <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> rte) <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR , <br /> t I CHECK If BILLING ADDRE <br /> I-0y <br /> BUSINESS NAME n ' 11 PF ONE# 'n ExT. <br /> t S <br /> HOME or MAILING ADDRESS 11 FAx# <br /> 41 <br /> CITY �YG STATECA ZIP � <br /> BILLING ACKN WLEDGEMENT: 1, 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 applicion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar E and FE <br /> APPLICANT'S SIGNATURE: 4 vti DATE: L' <br /> PROPERTY/BuSINESSOWNER❑ OPERrTOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING I)ARTY,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 to the SAN JOAQUIN COUN"fY 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: �)J <br /> COMMENTS: <br /> SEP 0 4 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: q DATE: <br /> ASSIGNED TO: c7\.(eS EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 06 I P 1 �oQZ <br /> Fee Amount: , S 2 i Amount Paid 1; - Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />