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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 /> CHECK If BILLING ADDRESS <br /> VII-LA L <br /> FACILITY NAME <br /> C"1 OGE2 <br /> SITE ADDRESS � bLe0 � t ( S �� S�Gl 2 'ds <br /> J <br /> Street Number Direction /� Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> i 2I 1?�l eGt nr�e <br /> Street Number I Street Name <br /> CITY STATE ZIP <br /> r r Y4- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE;t2 EXT. BOS DISTRICT LOCATION CODE <br /> 1•f+) ��� � JO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 20 U A LET LtG - v`� <br /> HOME or MAIL G ADDRESS /L _ FAx# <br /> CITY 54 <br /> C.'k MG^ STAT 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 iden''ed on this form. <br /> I also certify that I have prepared this applicat' n nd that the ork to be performe will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST E FEDERAL I <br /> APPLICANT'S SIGNATURE: DATE: 2'Z_A�__ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,Proof Of authorization to Sign is required pille <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: O 6 V �'7�/I V <br /> COMMENTS: <br /> Cin(A o WJowclwp - OCT 2 2 2018 <br /> I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE/$: DATE: <br /> ASSIGNED TO: L , - EMPLOYEE$/: DATE: <br /> Date Service Completed' (if already completed): SERVICE CODE: P/E: 1 1 1 . 0 <br /> �'\ 2 <br /> Fee Amount: C' cif) Amount Paid 1�J 2 po Payment Date lO � <br /> ZW`� <br /> Payment Typeq�66A V LSA Invoice# Check# Received By:�� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />