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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tpe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F F,� C <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 0,41 AQ S <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direc ion INU' 1. Street Name <br /> HOME Or MAILING ADDRESS (If Differ nt from Site Address) <br /> �� � Z LJG• <br /> Street Number Se"h G Street Name <br /> CISJ/ E ZIP�� <br /> PFIONE#1 EXT. APN# _ LAND USE APPLICATION# <br /> 'ICY <br /> PHONE#2 EXT. BOS DISTRICT, LOCATION CODE <br /> ( ) CAL <br /> CONTRACTOR / SERVICE/REQU/E��S�TOR <br /> REQ STOR 1 �` w ��k, I/,�.�iJ C O e Lcw- CHECK If BILLING ADDRESS <br /> BUSINF NAME PHONE# EXT. <br /> HOME or MAILING ADRESS FAX# <br /> ( ) <br /> STATE ZIP <br /> BILLING A KNOWLEDGEMENT: 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 /> 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �' DATE: Z fJ <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 01 <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 ISe QV_Ided to me or <br /> my representative. I"_Q/7�Y <br /> TYPE OF SERVICE REQUESTED: OI Ck— <br /> COMMENTS: AUG 28 <br /> �4o V 2018 <br /> li��RUNM�OUAI�y <br /> N flEP M NT <br /> ACCEPTED BY: 0,e f) ,`� EMPLOYEE#: DATE: -2 <br /> ASSIGNED TO: ��r--\ _-C� V. J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:Cl J"-.2 P I E: <br /> Fee Amount: t'7�P Amount Paid Ov Payment Date <br /> Payment Type C� Invoice# Check# /S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />