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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z l ro d d E c1 C i 1i lI i j c• S'` 1, <br /> OWNER I OPERATOR <br /> (�/ <br /> �+-.Y-v CHECK if BILLING ADDRESS E] <br /> FACILITY NAME I J <br /> SITE ADDRESS , jFZ CAJ Y)a Ld S R a W U 1,_0 C � <br /> Street Number Direction Street Name city / Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /r iii c V(/ <br /> G- Street Number Street Name%]/ <br /> CITY STATEzipZIP <br /> A <br /> C- r! <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> ( ) Sl a - !573 - ,5 10 61 <br /> [PHONE#2 EXT. BOS DISTRICT LocATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r I���C �� l <br /> c �{ �j( CHECK If BILLING ADDRESS <br /> BUSINESS NAMEAsk (1� m'ut� PHONE# <br /> q Z n q Z <br /> HOME or MAILING ADDRESS 2 - CC FAX# <br /> CITY �L �~ yH Jr{ n �Q STATE ZIP of Li�s j <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,STATE an-DER <br /> APPLICANT'S SIGNATURE: (// DATE: 3 0 <br /> PROPERTY I BUSINESS OWNER❑ OPE ATOR/M AGER b 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: FT-)ocl -Picol C'y1..1%C R <br /> COMMENTS: <br /> MAN 0 7 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT, <br /> ACCEPTED BY: `C, 7� EMPLOYEE#: DATE: _ 7- /9 <br /> ASSIGNED TO:' "7 (•�z� EMPLOYEE#: DATE:J.- '-7 - / �( <br /> Date Service Completed (if already completed): SERVICE CODE: J2 PIE: <br /> Fee Amount: Amount Paid ,_ Payment Date <br /> Payment Type C`T l Invoice# Check# Received By: <br /> �i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />