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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propert FACILITY ID# RVICE REQUEST# <br /> ou <br /> S�oD q-,�\�qo <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACIL Y NAME <br /> 4,�A- 'J <br /> S» EtAfDDRE �J� (�� 1710J ` <br /> I Stre t Nuamber Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> '�i <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2&P <br /> PHONE#2 EXT. BOS DISTRICT -7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOj � <br /> L A G`, _ f ^^ v/ ��� CHECK If BILLING ADDRESS <br /> BUSINESS NAME/C /�J ! J / ICJ �C� PHONE# / EXT. <br /> Z <br /> HOME Or MAI ING ADDRESS FAX# <br /> G e 14 ( ) <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 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: J` Z, v <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 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 I is provided to me or <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: �(J ' nS;�, EC <br /> COMMENTS: <br /> MAY 2 0 2019 <br /> S NV AQUIN COU <br /> HEALTH p NME ZANI Y <br /> MENT <br /> PAR <br /> ACCEPTED BY: fA(v`A 0 s O EMPLOYEE#: � DATE: <br /> ASSIGNED TO: `�l EMPLOYEE#: v DATE: �q <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: 0 (4-11 <br /> P/E: 6002 <br /> Fee Amount: ( Amount Paid 2 Payment Date 20 <br /> Payment Type V 15C�- Invoice# Check# Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br /> f X0523305' <br />