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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (�,fUk -7 -7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADORE S <br /> Street Number Direction / /` rest Name CI ZI Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /�f7 4-4.t Number Street Name <br /> CITY � J' DUSTT ZIP <br /> PHONE#'I *T`U �• APN# LAND USE APPLICATION# C, <br /> PHONE#2 BOS DISTRICT LOCATION ODE <br /> (:5 '? / O� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �` <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME / �1 , PH3/ ,9Y � 5 <br /> HOME Or MAILING ADDRESS �G i; 0 ^ � FAx# ) <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 ENVIRONME;$ITAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identif edon this form. <br /> I also certify that I have prepared this appli n at a ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE aws. <br /> APPLICANT'S SIGNATURE: � � DATE: G <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: f -P hg ' PAYMENT <br /> COMMENTS: ^�., /� � RECEIVED <br /> OCT 0 3 2018 <br /> EJOAQUIN COUN <br /> NVIRONMENTAL-TM <br /> moo TUFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I S� <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z3 PIE: VD <br /> Fee Amount: Amount Paid I�'g Payment Date 3 1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P"%3 9-7 <br />