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SAN JOAQ.i.J COUNTY ENVIRONMENTAL HEALTH JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CL)" <br /> - CHECK If BILLING ADDRESS <br /> — le <br /> AI ZZZ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name V�C � Zi Code _` <br /> HOME r MAILING ADD/ ESS (If Different from Site Address) <br /> ' 'V -�' `t` Street Number f -b Street Name <br /> CITY STATE ZIP ck 3p` <br /> L7 j tl <br /> PHONEA EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION1 CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> ��t"o- Lt� uLv, CHECK If BILLING ADDRESS <br /> BUSINESS NAME/ �J�/ PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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,S and FEDERAL laws. <br /> /� r — <br /> `,,,APPLICANT'S SIGNATURE: DATE: r� <br /> PROPERTY/BUSINESS OWNER e�l-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. PAVaq— <br /> TYPE OF SERVICE REQUESTED: -EA Gj✓1�jt l l�t��(p �� <br /> COMMENTS: <br /> AJV�1A <br /> Y 0 2017 <br /> SJOAQU COU <br /> HEALTH D pMeN-rAL <br /> ACCEPTED BY: A4Cu,-t-or�,(k EMPLOYEE#: DATE: 1)_CZ.- 17 <br /> ASSIGNED TO: l—� t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: , P I E: V h <br /> Fee Amount: C?o Amount Paid/, �j�/� Payment Date , 7 <br /> Payment Type ,�,. Invoice# Check At Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />