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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> AW 7-t <br /> R ES/SENT L S��Iym <br /> OWNER/OPERATOR <br /> IYIR—, S/,,41<� D u L ^ OnECK If BILLING ADDRESS <br /> FACILITY NAME/? <br /> SITE ADDRESS ��� Tn S FET $7Z�GGT'0N g S��pro <br /> Street Number Direction Street Name city Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) //Q Number 'd.c7 T Vic-8F—P'A <br /> Street/ Street Name <br /> CITY STATE ZIP <br /> S O CA <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> b�9) G- 00Y /7/- 5-/- 3 <br /> PHONE ill EXT. BOS DISTRICT =P <br /> ATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> D0,/V/ �� ICHECK if BILLING ADDRESS E] <br /> BUSINESS NAME / PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 0 . rovy ( ) <br /> CITY I ' n LOC ` 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 a cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, A E and FED laws. <br /> APPLICANT'S SIGNATURE: DATE:: <br /> 4 <br /> PROPERTY/BUSINESS OWNER 1:1OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LR/ <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 IS provided to me or <br /> my repr <br /> E UESTEM ,!K AC A <br /> NTS: <br /> ��N 0 5 2019 <br /> 1N C0,0MN �A t © I <br /> SPN 30V RONM RSMENT <br /> STN pEpA <br /> ACCEPTED BY: EMPLOYEE#: DATE: j_ <br /> ASSIGNED TO: V OF 1A EMPLOYEE#: 1,J DATE: ✓ <br /> Date Service Completed (if already completed): SERVICE CODE: r=,Z 3 PIE: Z�0 3 <br /> Fee Amount: 5 0� l]� Amount Pai 41 Payment Date <br /> Payment Type Invoice# Check#�S Rece ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />