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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> S 6Cw w <br /> OWNER 1 O TOR <br /> CHECK if BILLING ADDRESa <br /> FACiuTY NAME <br /> SITE ADDRESS t "� <br /> Street Number Direc ion � et a i <br /> HOME or MAILING ADDRESS (If Different from Site Addres ) <br /> Street Number Strwat Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (a U <br /> PHONE#2 ExT- [�O� <br /> LOCATION CODE <br /> ( o 1A - X13 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR \ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADD ESS FAx# <br /> ( <br /> CITY A o STATE ZIP t` <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 <br /> or 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,ST E law . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS O',PNFR❑ OPERATOR/N(NAG) OTHER AuTnORIZED AGENT 11 <br /> If.-1 PPLICANT is not the BILLING PARTY,prop of authorization to sign is required Tlrtr <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative <br /> TYPE OF SERVICE REQUESTED: h S Lt I D ✓1 ��a <br /> COMMENTS: ptcEill EI) <br /> MAYS 0 g 2019 <br /> SAN EN <br /> OAQUIN COUNTY <br /> HEALTH ONMENTAL <br /> ACCEPTED BY: {I-/l [�U r 5� h th { Z� EMPLOYEE#: A T3-J <br /> ASSIGNED TO: L }} ll��lltt+Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l �t P I E: <br /> Fee Amount: l b2 G U Amount Paid �s� Payment Date <br /> Payment Type S� Invoice# CheckZ (�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117t2003 <br />