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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LAtc� FADp�t,53 (A60� <br /> OWNER/OPERATOR 1 n � <br /> I J�On PJ I& f� CHECK if BILLING ADDRESS <br /> FACILITY NAME / f � `I _ ���///��\ ! <br /> t4 <br /> SITE ADDRES V <br /> S63/zµt N ��� S��h r�Vec� <br /> 1 Street Number Direction I S Name Ci �7��e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7 3�- <br /> Street Number '7 � Street Name <br /> CITY C•� 4- SiTE cl-5 j 0 <br /> PHONE#1 c� EXT. APN# LAND USE APPLICATION# <br /> ---] , <br /> PHONE#2 EXT. BIDS DISTRICT <br /> LOCATION CODE <br /> wet y57- 09C)I/ �s+nuranf I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME /' l I `� `1 PHONE/t n(A _ l /� EXT, <br /> HOME or MAILING ADDRESSl��� n i FAX# p <br /> L'�,,{//.� l ( Xvc ( ) <br /> CITY /1 cK✓� STATE C� 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 /> I also certify that I have prepared this ap ' ation an at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TATE a FEDERAL ) <br /> APPLICANT'S SIGNATUR DATE: �� '2� / <br /> PROPERTY I BUSINESS OWNER O MAN R ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING 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 to me Or <br /> my representative. 11 <br /> TYPE OF SERVICE REQUESTED: �Xn (o lC- <br /> COMMENTS: <br /> 2 4 2018 <br /> N COUNlY <br /> ,Z le ni e n-� 3K r�c�!-�.oa • w rn SAENVIRO MENTAL <br /> ENVIRONMENTAL <br /> HEALTH DEpARTMEh T <br /> ACCEPTED BY: i" ? �� •� EMPLOYEE#: DATE: L7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 23 PIE: J Lr) '• i <br /> Fee Amount: Amount Paid — Payment Date 1 L l <br /> .'l r <br /> Payment TypeV/ S Invoice# Check# Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />