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L vet I'G�-i}- SAN JOAQUIN COUN NVIRONMENTAL HEALTH DEPARTMENT <br /> ,�,,,�,,,,,,SERVICE REQUEST <br /> Type of Business(Ir Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPE OR <br /> v� // �• CHECK If BILLING ADDRESS C� <br /> FACILITY NAME <br /> SITE ADDRESS J <br /> Street Number I Direction Street Name CI Zio Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Str¢¢t Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr• APN# LAND USE APPUCATION# <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> 1 CONTRACTOR//SERVICE, REQUrESTOR <br /> REQUESTOR , \ CHECK if BILLING ADDRES <br /> BUSINESS NAME yq PHONE# ExT• <br /> 2c o v <br /> HOME or MAILING ADDRESS FAX* <br /> CITY 1� l�/ 1i �`/, r�(� STATE ZIP 4 <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,Standargs,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY i BUSINESS OWNER❑ OPERATOR i MANAGER ❑ OTHWAuTHORIZED AGENT <br /> if APPLICANT is not the BILLING PARTY.Proof of authorization to sign is requireli- 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the samIS It is provided to me or <br /> my representative. + Mau- <br /> TYPEPE OF SERVICE REQUESTED: ( ff' �G///,p- M iZA-s7� J <br /> COMMENTS: 2--tt C— APR 01 2019 <br /> SAN JOAQUI, <br /> ENWRONA# COUN7Y <br /> H�-TF1 OE ARDENT <br /> ACCEPTED BY: ��f e(,y K EMPLOYEE M DATE:.1�t"� 1 s� <br /> ASSIGNED TO: EMPLOYEE#: DAT --t <br /> Date Service Completed (i ready completed): SERVICE CODE: 52,3 I IP/E:/ <br /> Fee Amount: Amount Paid 420 4.0 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> k = 0 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> NA 13q <br />