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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ PERAT <br /> CHECK If BILLING ADDRESS <br /> FACpiv NAME <br /> SITE ADDRESS 9 5�07 <br /> 4`7 /�/J <br /> ��CS ' rStreet Number Direction / � S rt e t Name "" G�C Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> �S /Si'i L✓t'l� 6J 4 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAM EE� ' PHO # Ext. <br /> . ' e- NE C's cam=--� ONE 3 G? - —70 7� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY�L`,�cl / / StT9TE 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 /> 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,STA E and FEDERAL laws. /l <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER J0 OPERATOR/MANA ER ❑ 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 assment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time { yided to me or <br /> my representative. �1 op�Y/J� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: CY _ i n CJ�Ysrup %-/, I9 2018 <br /> y y r�7 Q>V/N O <br /> RO C <br /> yOFP MFN <br /> ACCEPTED BY: -(41 f Y-'ryQ2 EMPLOYEE#: DATE: 5h9I y <br /> I <br /> ASSIGNED TO: I J'C cnU-t 'L EMPLOYEE#: DATE: � 11I IJ <br /> I <br /> Date Service Completed (if already completed): SERVICE CODE: �C I PIE: I S L <br /> Fee Amount: ` Amount Pai /sa.D D Payment Date 3 <br /> Payment Type C � Invoice# Check# 1��� ' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />