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SAN JOAQUIN' COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESLI <br /> �NER/OPERATOR`� CHECK IfBILLING ADDRESS® <br /> FACILITY NAME /�/t I <br /> SITE ADDRESS � � ',T <br /> r e�L' St/�rTeet <br /> ? Street Number DlrecHm I rName P-0141- <br /> /_d 1/�T JPPTVI-G�c A ZI Cotl^ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number heel Name <br /> CITY STATE zip <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( I PA- Ib1 (515 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONT i[ C i OR SERV ICE co Q ES Y QR <br /> REQUESTOR <br /> O CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> D - <br /> HOME OrMAHING ADDRESS FAX# <br /> © C ( ) <br /> CITY STAT 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 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 laws. <br /> APPLICANT'S SIGNATURE: �� DATE: G <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR I MANAGER OTHERAUTHORIZEDAGENT ❑ <br /> If APPLIQANTis not the BILLING PARTY proof Of authorization to sign is required Titfe <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: c �U <br /> COMMENTS: <br /> lC M PAYMENT rep <br /> yja RECE.IVED <br /> SEP 12 2016 <br /> ACCEPTED BY: EMPLOYEE#: SAN JFINVIOAH <br /> ASSIGNED TO: • 7-o J S EMPLOYEE#: HEALTH A : _/� <br /> Date Service Completed (if already completed): SERVICE CODE: - P 1 E: C <br /> Fee Amount: a'7OCe) <br /> AmountPaid a �- '-� Payment Date �D r ; <br /> G <br /> Payment Type CIC Invoice# Check# tReceived By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />