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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID A SERVICE REQUEST# <br /> r 5 S�a i 0.n f �� :r c� 1 <3(L -7`7��`�� � <br /> OWNER/OPERATOR <br /> 1 CHECK If BILLING ADDRESS <br /> c Li Lw -3`t' C' /lv\tct, Cyt <br /> FACILITY NAME (Z L)D <br /> SITE ADDRESS Direction �� a <br /> SIt <br /> Street Number ree Name CI i 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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Z��� <br /> �2-Q � CHECK If BILLING ADORES <br /> BUSINESS NAME , �(�tC C,:o-k V,1A t-a"G+ ' PHONE# J Ext. <br /> �� S� Gt to i <br /> HOME or MAILING ADDRESS D� 17 >� I�Cf 4 FAX <br /> CITY + �( (_ �_ 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 /> 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 Z <br /> d E L laws. <br /> APPLICANT'S SIGNATURE: _ = DATE: (� l� <br /> PROPERTY/BUSINESS OWNEfinot <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [IIf APPLICANthe BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 tlmepj4�p�gvided to me or <br /> my representative. ^1 MZAI'r <br /> TYPE OF SERVICE REQUESTED: i I►I <br /> COMMENTS: MAY2017 <br /> SAN j04QU/ <br /> HaQki O'�fr�Ty <br /> FNT <br /> ACCEPTED BY: CEMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: lI ci l/ PIE: <br /> Fee Amount: [� O Amount Paymen`t'DDate <br /> Payment Type 1/7 1,) Invoice# Check# So2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />