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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH br-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> D ✓ ( �i � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 6 r(o <br /> t'T�.�"'�P^L r G4�L J•1 � .� �'Fo c.V�'u.-� 7�7JU <br /> Street Number Direction Street Name Ci ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> i o�"Lr7'7 �L 7ri „c <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> S .�-�� k I--.. C t� SZoei <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZO ) '730- 3z-;3 E cc 2-e) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Sv w� Z- y31 - i <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY �+ �. STATE C ZIP s 2-C'J <br /> Jl <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, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: G 1�� , DATE: I X2-2-1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 /> t0 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: L -- COS 1 P~ <br /> COMMENTS: <br /> JAN 2 2 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT jJ <br /> ACCEPTED BY: �j _ _- _ EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> i <br /> Date Service Completed (if already completed): SERVICE CODE: ` ) PIE: <br /> Fee Amount: !!N 1 52_- Amount Paid y c Payment Date I . 0 D' .1 <br /> Payment Type C-IL' Invoice# Check# 1 -70 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />