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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2C)0�I �3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Ci---1'0 F g f\ <br /> V•'P�+ <br /> SITE ADDRESS J (/1, �1�C I-�-�t, P _I I(,-I C7y) <br /> Street Number I DStreet Name iCi Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 2L4 5— O--�t --�� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> I <br /> I BUSINESS NAME PHONE# _ ( I EXT. <br /> HOME or. ADDRESS FAX# <br /> <� 110 ( ) <br /> CITY p0n; STATE ZIP <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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST and FE R L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not th BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE IN ORMATION: 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: <br /> COMMENTS: <br /> aN 3 2018 <br /> NVIIHONMENTAL HEALTH <br /> 'FRIUITrSER%ACES <br /> ACCEPTED BYEMPLOYEE#: DATE: 112 IQ/ <br /> ASSIGNED TO: EMPLOYEE#: DATE: t DD <br /> Date Service Completed (if already completed): SERVICE CODES t;r)3 P/E: <br /> Fee Amount: -� I W Amount Paid 130 Payment LDate 01 i3 I Ic <br /> Payment Type C' PCG Invoice# Check# 3g S� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />