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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# WRVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME f <br /> c <br /> SITE ADDRESS / 9^ I n n I Rp� �3~� <br /> Street Number Direction U/4' treet Nam Ci Zi 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# I-ND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE <br /> p# �4 O EXT. <br /> HOME or MAILING ADD 'J FAX# <br /> CITY STATE �A ZIP <br /> D <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 F ERAL laws. <br /> APPLICANT'S SIGNATURE: 11 DATE: 7L / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® <br /> kz <br /> I{APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tifle <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: r i <br /> COMMENTS: <br /> r C <br /> MAR 2 7 2019 <br /> /7 If SAN INC UNTY <br /> ACCEPTED BY: f,I� EMPLOYEE#: DATE. I A <br /> ASSIGNED T0: vl t} V1 C EMPLOYEE#: DATE: /2�/� <br /> Date Service Completed (if already completed): ` SERVICE CODE: P(/E: (�!202— <br /> Fee Amount: Z Amount Paid i J _ Payment Date <br /> Payment Type Invoice# Check# Received By: V/' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />