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SAN JOAQM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR <br /> CHECK if BILLING ADDRESS f <br /> FACILITY NAME <br /> SITE ADDRESS 2�O <br /> 7 Street Number Direction SVee Name ,U(-- 6ZI�Co <br /> HOME or MAI NG ADDRESS (If Differentfsom Site dress) <br /> Street Number Street Name <br /> C'I STATE Zip <br /> PHONE tf APN# LAND DSE APPLICATION# <br /> ( D <br /> PHON #Z T. BOS DISTRICT LOCATION CODE <br /> �Z i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L CHECK If BILLING ADDRESS <br /> BUSINESS NAME O PHONE# En. <br /> HOME or MAILING ADDRESS r r FAX# <br /> CITY n STAT zip .� <br /> BILLING A KNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent if 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, STAT FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNEROPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i not/the BILLING PARTY,proof of authorization to Sign i5 required Tirle <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 /> to 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. <br /> TYPE OF SERVICE REQUESTED: Fo hcifi PAYMENT <br /> COMMENTS: REGGIVED <br /> NOV 0 8 2016 <br /> SAN JO JOAQUIN <br /> COUNTY <br /> NTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: r EMPLOYEE#: DATE: <br /> ASSIGNED TO: I D EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: t:7)4-) PIE: Qa <br /> Fee Amount: 00 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/77/08 <br />