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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/OPERATOR <br /> S CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS qy` ' T (:A 9 �� <br /> ((Street Number Direction Street Name c1tvZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) '(q►V/t1 _ <br /> eet Number `�' r t Name <br /> CITY STATE zip <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) bos 6t-1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> U L Lu/' o i I I�C l,� CHECK If BILLING ADDRESS <br /> l•`( 1 Y PHONE# EXT. <br /> BUSINESS NAME T-n ,A C� cC�� / _ � <br /> HOME or MAILING ADDRESS FAX# lfJ <br /> r <br /> TY MCVr)+eCL� 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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: kJ wv�4 DATE: O LI-- <br /> PROPERTY/BUSINESS OWNER R 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 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: Q I (/14 PAYWILAT <br /> COMMENTS: RECEIVED <br /> APR 10 2018 <br /> OUIIM <br /> ENVIRONMjoAQUINEN AL <br /> ACCEPTEG nY: ( (/ C,J( EMPLOYEE#: llrErl �' ! , <br /> 1� I <br /> ASSIGNED TO: A- �, l EMPLOYEE#: DATE: OV ll <br /> Date Service Completed (if already/completed): SERVICE CODE: PIE: <br /> Fee Amount: v_ Amount Paid ' c� — Payment Date Lf <br /> Payment Type Y;S Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 79 S• <br />