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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST C- UD "'N 0 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW OPERATOR <br /> � CHECK if BILLING ADDRESS <br /> FACILITY AM <br /> SITE ADDRESS <br /> Street Number Direction _ Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different frpm Site Address) � Grl <br /> SStreet Number Street Name <br /> CITY TATE zip <br /> PHONE#1 EXT. APN# <br /> )�-�t�lLAND USE APPLICATION# <br /> ( o_ 1_ L 1000 w <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REC!UESTOR <br /> \ ` I(p CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1�— PHONE it Q EXT. <br /> 'Q C tS - <br /> HOME or MAILING ADDRESS FAX# <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 /> also certify that I have prepared this ap 'cati n and that th worki to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, T an FEDER law rr # <br /> APPLICANT'S SIGNATURE: DATE: L�—S - <br /> PROPERTY/BUSINESS OWNER❑ OP 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: P lew- <br /> 0- l ec <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 Z EMPLOYEE#: DATE: Li <br /> Da'aService Coinpleted (ifairead completed): SERVICE CODE: � PIE: <br /> FeP Amount: G Amount Paid Payment Date <br /> f <br /> Payment Type ,' Invoice# Check# P/\Y Received By: <br /> EHD 48-02-025 APR 0 S 2016 SR FORM(Golden Rod) <br /> 07/17/08 SAN JOAQUIN COUNTY. <br /> ENVIROMENTAL <br /> HEALTH DEPAR rMENT <br />