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SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY tD# SFRVICE REQUEST# <br /> OWNER I OPERATOR �. <br /> - CNt=cK if BILLING ADDRESS <br /> FACILIre NAME / <br /> SITE ADDRESS C <br /> 62 / Street Number Direction Street Name City Tia Cod:+ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2—& N h G %O - Street Number Street Name <br /> CITY STATE ZIP <br /> GIG/� � �f3�CP <br /> PHONE#1 ExT• APN# LANO USE APPLICATION I <br /> ( y� ySCo - -17/(4, 6go -1 � <br /> PHONE## EXT, BOS DISTRICT LOCATION CODE <br /> xe ) 1 - <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE I ExT. <br /> HOME or MAILING ADDRESS FAx4 <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 assbdated with this project or <br /> activity will be billed to me or my business as identified an 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 Jaws. <br /> APPLICANT'S SIGNATURE—, DATE: �— c —� <br /> PROPERTY/BUSINESS OWNER❑ E OR I VAANAGER CI OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is n0 the BILLING PARTY,Proof of authorization to sign s required Title <br /> AUTHORIZATION TO REL,I~ASB 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 environmentallsite assessment information <br /> to 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: R <br /> COMMENTS: <br /> JqN <br /> X 1-7 SgFNo ?4�5 <br /> hl�g4r.-IO9 Af <br /> TM <br /> N Act <br /> ACCEPTED BY: r f,]�f1.i EMPLOYEE it: DATE: <br /> ASSIGNED To: f 7 10� EMPLOYEE#: DR7E: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 3 DAmount Pai j Payment Date <br /> Payment Typeinvoice# 1 Check T Received E <br /> EHD 48.02-0".5 SR FORM(Golden Rod) <br /> 07/17108 <br />