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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> N+V �'w V <br /> OVVNER�-OPERATOR <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME 6 6-? <br /> SITE ADDRESS »� �� r�� <br /> Street Number Direction Street Name Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 7 U(711-1 FrLQ d�//l <br /> 5� Street Number Street Name <br /> CITY, I .�� <on s�A ZIs z <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> cZv�i �9 v 3�l2, ? <br /> PHONE,j/2� / f EXT. BOS DISTRICT LOCATION CODE <br /> c? <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> -(-2 CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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: cif 7 ���-� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Elif APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tiff <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. -AA 1L <br /> TYPE OF SERVICE REQUESTED: SU 1-j- It o <br /> COMMENTS: <br /> p1Z 05 � 3�(o MAY 16 2019 <br /> L S D /V U q VUI <br /> /RCOUIyN OA ) ' <br /> THpPR7L <br /> ACCEPTED BY: �m n ) EMPLOYEE#: DATE: <br /> ASSIGNED TO: nl1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): (p/I SERVICE CODE: & I P/E: <br /> Fee Amount: . 6D Amount Pa' �� Payment Date �� f <br /> Payment Type Invoice# Check# Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />