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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> /e re SG L l_( CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME y <br /> SREADDRESS ?53/ FC Ct/'C�✓1 <br /> Street Number Direction Street Name cityZi 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# <br /> ( ) l/ (3 / ^ LAND USE APPLICATION# <br /> PHONE#2 ExT• C/ BOS DISTRICT / LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME � PHONE# EXT. <br /> �actr�; 5 /t l_ 7--3,3-34 <br /> HOME or MAILING ADDRESS L FAX# <br /> I I 01 -7 S / (01!) <br /> CITY ,yI^c_-- STATE C Q ZIP Ct 53 5- <br /> BILLING <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 applica'on and tL to be performed will be done in accordance with all SAN JOAQUIN <br /> COU1v"IY Ordinance Codes,Stan rds,STATE nd F -R <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AG.ENTEa LGtq <br /> IfAPPLICANT is not the Bmayg PARTY,proof of authorization to sign is require Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, herebv 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: IAGLA <br /> COMMENTS: CE/VFX <br /> MAY 0 8 2019 <br /> SANjOIRHEAtpQN/N COUN1y <br /> ACCEPTED BY: EMPLOYEE#: DATE, PARTMEN <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: + Amount Paid � �S�� , Payment Date <br /> Payment TypeLf S Invoice# Check �4+G1�7 y31"7 Received By: L,17 <br /> J <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 � <br />