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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK IT BILLING ADDRESS <br /> FACILITY NAME L <br /> SITE ADDRESS !-- /� <br /> Street Number otlo • �" Code <br /> HomE or MAJUNa ADDRESS lif Different from Site Address) Ed1,G(rL�Lf./..- <br /> Street Number Street Name <br /> CITY A ZIP <br /> PHONE#1 ETT' APN0 LAND SE APPLICATION# 7 j/ <br /> ( I(9 2 7- 0 1 B - l Oa 30 <br /> PHONIER ETT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> 1 <br /> BUSINESS NAME1 PHONE# ETT' <br /> fyvv <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ! STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 lawwss1 / <br /> APPLICANT'S SIGNATURE: I/7 �� I��/Z}E?'✓" V DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER�, OTHER AUTHORIZED AGENT 13 <br /> I,fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVIC f <br /> COMMENTS: RECEIVED <br /> JUN 01 2018 <br /> SAN JOAQUIN <br /> COUNTY <br /> ACCEPTED BP' EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed if already completed): SERVICE CODE: P IE: p <br /> Fee Amount: Amount Pal!%3 , OD Payment Date <br /> Payment Type CNS Invoice# Check# '7L Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />