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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# i <br /> ��� S �3 <br /> OWNER r OPERATOR V <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �o � 5+,� p r 9sZC*-O <br /> Street Number Direction Sfreet Name city Me 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# LAND USE APPLICATION# <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRES$1 <br /> 'Sr GOND SE�ov-J - -�bNQ� C�tSTtLJrD <br /> BUSINESS NAME PHONE# EXT, <br /> SELOt-sa �E�sbH t i�- <br /> HOME or MAILING ADDRESS FAX# <br /> CITY s- � STATE GA zip 20 3 <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 farm. <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,Standards, ST nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: e J F5 <br /> PROPERTY 1 BUSINESS OWNER® OPERATOR/MANAu R 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 loca �ove <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses n krr <br /> e, <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time it is 5 M <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: UG 0 a 201 <br /> COMMENTS: 14. tJ,�'/1 - JOAQLiN CO�DEPAR <br /> N ry <br /> t <br /> 14- <br /> ACCEPTED <br /> 1ACCEPTED BY: EMPLOYEE#: DATE: _ <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: P 1 E:r Q. <br /> Fee Amount: 5 Amount Paid #Sz Payment Date I -7 <br /> Payment Type V ±s G-_ Invoice# Check# Received By: <br /> qZ'-�EHD <br /> 48-02-025 SR FORM{Golden Rod) <br /> 17/OB <br /> e <br /> scC 2 . 30 <br />