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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typof Business or Property FACILITY ID# SERVICE REQUEST# <br /> — It} off-- 02� I -J[ 107 <br /> OWNER/OPE TOR o <br /> �� C�I�� � � C-9��� CHECK If BILLING ADDRESS <br /> FACILITY NAME NJ 1 LLA c- T\ Lw l— G qO <br /> SITDDRSS <br /> Street Number I Direction O Lim R WJ St ame <br /> HOME Or MAILING D f SS (If Different from Site Address <br /> 'Jl C Street Number Street Name <br /> CITY � STAT ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE 12 S�r�— EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' I <br /> vL CHECK If BILLING ADDRESS <br /> BUSINE S NAME UR te V< < 0n� PH ,EXT. <br /> Ho" or MAILIN DDRESS FAX i— <br /> ZS U �) fs J <br /> CITY STATE ZIP \��I <br /> BILLING ACKNnyJ1 EDGEMEN : 1, 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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �5 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ �9L�1r\c LUL <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 ISDr <br /> �� � <br /> my representative. 1f 1 <br /> TYPE OF SERVICE REQUESTED: fwd <br /> COMMENTS: AUG 14 2019 <br /> SAN JOAQUIN COURry <br /> war'y OF O�nV/�f �(p ENVIRONMENTAL <br /> HEALTH DEpARTMEI IT <br /> ACCEPTED BY: S EMPLOYEE M Ct 8�j v DATE: 1 <br /> ASSIGNED TO: EMPLOYEE#: <br /> � ✓8 DATE: <br /> i <br /> Date Service Completed (if already Completed): SERVICE CODE: ( I E: <br /> Fee Amount: r1 UV Amount Paid / S 2 Payment Date G l <br /> Payment Type Invoice# Check# Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 aycfco <br />