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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ILCcl S M-7q SZ0 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> A <br /> SITE ADDRESS ��2f>ND C-ANAL- F�-L-vP ���� qg=�, <br /> Street Number Direction Street Name city zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LLAND APPLICATION# <br /> b \130Lp <br /> PHONE#2 EXT. RICT LOCATION CODE <br /> (209) S t� 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Mp S <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY S ATE zip (�R-•L 2 <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 /> 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,Stand s, TA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: (_TIIB <br /> PROPERTY/BUSINESS OWNER PE TOR/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 it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: SCEIVED <br /> COMMENTS: <br /> cage, � JUL 3 1 2018 <br /> BAN JOAQUIN COUNTY <br /> NTAL <br /> IjM.JH DONEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: ) V <br /> ASSIGNED TO: I EMPLOYEE DATE: -7_ _ SC <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: u <br /> Fee Amount: I 00 Amount Paid ``�2,W Payment Date —7 3 I t� <br /> Payment Type Invoice# Check# Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />