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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ERVICF REQUEST # <br /> 0 <br /> OWNER / OPERATOR / <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME LLL <br /> SITE ADDRESS Y . ' <br /> Stree umber Direction 1`�? lZiStreet ame Ci Zi Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) j �- <br /> .i <br /> Street Number Street Name <br /> CITY �� STATE / 'n ZIP - 1 /' <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> 47 11 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADORES <br /> BUSINESS NAME PHONE # EXT, <br /> HOME Or MAILING ADDRESS �7 �- �� �jj C f2� FAX # <br /> CITY �! STATE ;,OefZIP <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 la <br /> APPLICANT' S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPEAMIZ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, 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 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: <br /> s lvdo <br /> q U, 2019 <br /> 00t U N�� i D pq ENTq�N>]' <br /> I 4, <br /> ACCEPTED BY : - ELLA EMPLOYEE #: Ct P, I DATE : IJ i J RTME�T <br /> r b (T 1 l <br /> ASSIGNED TO : EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : a (� PIE : �I <br /> Fee Amount : efl C11 Amount PaicLpqu , to Payment Date o2 ll <br /> Payment Type Invoice # Check # � Z Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />