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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 /> A �s L c— CHECK If BILLING ADDRESS❑ <br /> FACILITY NAM "r k�C/lH <br /> SITE ADDRESS <br /> HOME or MAILING ADDRESS (if Different f om Site Address) �zy <br /> L Street NumMr i6k Ix�tc�Ct Name <br /> CITY STA Z <br /> PHONE#1 ET• APN# <br /> LAND USE APPLICATION# <br /> 522 6 G2 <br /> PHONE#2 EXT. BOS DISTRICT c LOCATION C E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR" — - � {� <br /> am, CHECK If BILLING ADDRESS W.1 <br /> BUSINESS NAMEP l E <br /> l^ # /r.51_ <br /> Ho or MAIL!, ADRESS. FAX# (� <br /> CITY V _ 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 <br /> or 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,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: N k DATE: 0b.2Jh- <br /> PROPERTY/ <br /> BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If21/71_! <br /> *Jle APPLICANT is not the BILLING PARTY.proof of authorization to sign is required - f le <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. AA <br /> TYPE OF SERVICE REQUESTED: � L�- �� <br /> COMMENTS: � D <br /> �Pric(V1q'e CP O�er UN 08 2018 <br /> S�'EF/VVIR 1N CCUIVTy <br /> HEATH SEP SIV <br /> ACCEPTED BY: f� EMPLOYEE#: DATE: ctt <br /> ASSIGNED TO: EMPLOYEE#: DATE: / (/ <br /> " <br /> Date Service Completed (If already com eted): SERACECODE: G'�j / pl : l�aZ <br /> Fee Amount: �JZ` Amount PaidPayment Date SSG <br /> Payment Type �� Invoice# Check# 21 v�_7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 � I� Cx� <br /> PP�,x(07 (0 v -51 <br />