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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1? M7';� `�� <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS D <br /> FACILITY NAME / Q <br /> SITE ADDRESS o2G 783 /V G'/�{�/QO/�GEE L iQ/S/� OD 7 5�3Z <br /> Street Number mmction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SAStreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> too > <br /> 0/0 -35-03 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) r� c1`I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' <br /> O E y_- ' CHECK If BILLING ADDRESS <br /> BUSINESS NAME-bOA( <br /> G PHONE# EXT. <br /> C E � (S� <br /> HOME or MAILING ADDRESS FAX <br /> O ( ) <br /> CITY O 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 preparedthis lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, T E and FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR MANAGER ❑ THEIR AUTHORIZED AGENT <br /> If APPLICANT Is not the BILLING PARTY,proof of aut orization 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 i rovided- - Or <br /> my representative. - <br /> TYPE OF SERVICE REQUESTED:N/7-pAr <br /> AP 4 4a i fA 014 ACCMSSIFfOd v <br /> COMMENTS: <br /> A �A <br /> MAR 2 2 2018 { <br /> SAN JOAQUIN COuNTy <br /> ACCEPTED BY: t EMPLOYEE#: HEALTH DE A �AL �_�v <br /> ASSIGNED TO: in�. EMPLOYEE#: DATE: a O <br /> Date Service Completed (if already c mpleted): SERVICE CODE: 5-—2P 1 E: Z� <br /> Fee Amount: G(_C'1�1 Amount Paid C Payment Date R <br /> Payment Type C,,IOC Invoice# Check# 3 Received By. `C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/Ob <br />