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/�90 i/ 7 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR / CHECK If BILLING ADDRESS ❑ <br /> elleyVvVitl DrrJ GAS �y� <br /> FACILITY NAME � <br /> d'1� VVDF'1 � �Ui ,3 �3 <br /> SITE ADDRESS / �J r,� <br /> 196C) Street Number Dlirreection Street Name /lam Jcitv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name 04 <br /> CITY STATE ZIP ` 1 / T <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICTt CLl7)ON1FI DE 77 <br /> oNVL�O ti 1 t'OUilr -), <br /> CONTRACTOR / SERVICE REQUESTOR °Pp � i11 <br /> �, � <br /> REQUESTOR <br /> ��� � G✓1 ems✓ CHECK If BILLING ADDRESS <br /> BUSINESS NAME O PHONE # ExT. <br /> HOME or MAILING ADDREAS / L FAX # <br /> 030 <br /> GIS /► v (' �l t -�t � ( ) <br /> CITY STATE ZIP �jf� �` <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 : <br /> DATES <br /> �� <br /> PROPERTY / BUSINESS OWNER ❑ PERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT y� ,��l,� S'c �eoe% is <br /> If APPLICANT IS n he BILLING PARTY. /goof 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site 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 : <br /> COMMENTS : ?' <br /> FEB 0 5 2019 <br /> ENVIRONMENTAL HEALTH <br /> PFRfy1lT/SFR \/IrFq <br /> ACCEPTED BY: / t C UAIA:) EMPLOYEE # : DATE: <br /> ASSIGNED TO : y e \ n l EMPLOYEE # : C' �f jm 1 DATE : <br /> Date Service Co pleted ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount : Amount Paid L � �� Payment Date <br /> Payment Type Invoice # Check # Lkl Rece' ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />