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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business Property FACILITY ID# � o VICE R�QU 1-) # <br /> 0Zov <br /> OWN>�QPERAgR <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS wfa ' 0 <br /> Street Number Direction Street Name Ci Zi Code ' <br /> HOMEor MAILING ADDRESS (if Different <br /> t froom Site Address) <br /> 2 fl 0'Mao r// �enV Street Number Street Name <br /> CITYn ST64 (T41� i` <br /> ly <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> (2 ) qi )_i�H 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR g A <br /> �], CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1"l�1 A t( PHONE# I 5M <br /> EXT. <br /> HOME or MAILING ADDR�SS FAX# 10C l( <br /> 231I IU - E1 DOVaJ ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business o/ �j wnner, 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, E nd ERA ws. <br /> APPLICANT'S SIGNATURE: DATE: �D <br /> PROPERTY/BUSINESS OWNER OPERAS: R I 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 �F(yvM1E Or <br /> * <br /> my representative. mM�� <br /> TYPE OF SERVICE REQUESTED: <br /> :Plain ckck IMECEIVED- <br /> COMMENTS: JUN 2 0 2019 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: aIA M EMPLOYEE#: 0 DATE: (P12,0184 <br /> ASSIGNED TO: viEMPLOYEE#: DATE: <br /> / 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: f <br /> Fee Amount: 5V '�(� Amount PaidS ment Date <br /> Payl <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />