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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /d-r�T r'�s 2-t S�(P_+ O <br /> OWNER/OPERATOR <br /> � I CHECK If BILLING ADDRESS <br /> FACILITY NAME (l Y�/V <br /> SITE ADDRESS bII /��r5t e <br /> Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 3,1110070 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) o05 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> � CHECK if BILLING ADDRESS <br /> BUSINESS NAME vI PHONE# EXT. <br /> HOME Or AILINGJQDDR� � ^ � FAX# ) <br /> CITY $TATE �` ja- <br /> 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 ' entified on this form. <br /> also certify that I have p epared this licatio d that t k to be erformed will be in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, tandar ,S TE a FEDERAL 1 <br /> APPLICANT'S SIGNA DATE: <br /> PROPERTY/BUSINESS OWNER❑ `t3PEftATO /MANAGER ❑ HER 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 a5 soon as It 1S available and at the same time It Is <br /> my representative. P M <br /> RECEIVECI <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: e� vtg 4 �, JAN 11 2018 <br /> " `7 SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed Vf already C pleted): SERVICE CODE: S Z -5 PIE: <br /> Fee Amount: 5— Amount Paid Payment Date <br /> Payment Type Invoice# Check# ggi " Received By:� <br /> C (C— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 7 3 6 3 s <br />