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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />4' (\ 0 + V ' Q VA -c l <br />` t <br />FACILITY ID # <br />SERVICER ESI # <br />OWNER / OPERATOR <br />4 <br />CHECK if BILLING ADDRESS 11 <br />FACILITY NAME <br />art ° I r� <br />HOME Or MAILING ADDRESSI <br />SITE ADDRESS I !� <br />Street Number <br />C <br />Direction <br />ii <br />i�T <br />Street Name <br />A v fit <br />j �.� rY Or <br />Ci <br />_ <br />� � 0 5 <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />CStreet Number <br />\ // <br />`r u "e �^ `� Street Name\ <br />CITY' Z `Ill I <br />STATE ! �� -3734 <br />PHONE #11 �\ EXT. <br />(91B 7 // <br />APN # <br />DATE: I I <br />LAND USE APPLICATION # <br />PHONE ill EXT. <br />( ) <br />SERVICE CODE: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />'L ti- <br />4' (\ 0 + V ' Q VA -c l <br />` t <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PAYMENT <br />PHONE # EXT. <br />HOME Or MAILING ADDRESSI <br />.� t J � (� ` <br />\V/ <br />(AX # 6., ` q q J <br />CITY %t . L ' „j <br />STATE e A + zip 7 1 <br />BILLING ACKNOWL DGEMENT: 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, Standard,44TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:, DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ 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 />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: ! 11— <br />�� <br />�•r <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />MAN 1 1 2019 <br />SANK JOA <br />ACCEPTED BY: + z �.i _—_--�—� <br />EMPLOYEE M <br />`�IJ [RO TP G <br />s l HEALTH <br />ASSIGNED TO: , <br />EMPLOYEE #: <br />DATE: I I <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: ML <br />Amount Paid <br />C) <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />am <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />