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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEe REQUE T# <br /> `7 C7 3 �l uv Q A 6^ <br /> OWNER/OPERATOF5� /�/I <br /> �J� ` C 'Or� CHECK If BILLING ADDRESS <br /> 11 <br /> FACILITY NAME t��G C• l <br /> SIT DDRESS ^/�r� )�e �C,J <br /> Strect Number Direction /V [ Streel Name ( / ,Cit Zi Code <br /> HOME 0 AILING AMRESS (If Differ nit!fromsiittee Address) <br /> Street Number Rt-et Name <br /> CITYtJ . ZIF <br /> PHONE#1 EXT. APN# LAND USE APPLICATICN# <br /> c ) 2l -o .. <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ;1 - alt <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRE <br /> /ate C 017ler17 <br /> BUSINESS NAME C PINE EXT, <br /> HOME or MAILING ADDRESS FAX# <br /> STA € ZIP U�jI I <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project'specific ENVIRONMPN I AL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on is form. <br /> I also certify that I have prepared this appli- and tl.Lith work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,SI(tndurds. ' An d FI=I -s. l <br /> APPLICANT'S SIGNATURE: DATE: <br /> � <br /> PROPERTY/BUSINESS OWNER 0 . ATOR/MANAG6:14 ❑ OTHER AUTHORIZED AGENThhwr Itt?6cT. <br /> If APPLICANT is not the .l.l,V(-,PART)',proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of1he 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: RMFIVEn <br /> COMMENTS: <br /> JAN 2 2 2019 <br /> (5 SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: _ta w e EMPLOYEE M DATE: ` <br /> ASSIGNED TO: UA U\al! EMPLOYEE#: DATE: f <br /> Date Service Completed (if already completed): SERVICE CODE: L3 ` PIE: <br /> Fee Amount: �. Amount Paid5�p _ Payment Date <br /> Payment Type I S Invoice#. Check# Received By: 1 � <br /> L=I•ID 48-02-025 Con-�tf qIr K& -7 ?67'-2 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />