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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LA 11-7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME rV/G /Y11ur <br /> SITE ADDRESS 713 t / ��G��� j � �yl 4f' �Z Q3 <br /> Street Number DirectionZio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9 '1� <br /> (Street Number /�/ Street Name <br /> CITY�1 STATEC /l/J� ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> chi ) *?' t) � — $q33 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR it SERVICE REQUESTOR <br /> REQUESTOR '7 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /� PHONE# EXT. <br /> HOME or MAILING ADDRESS 11 FAX# <br /> 713 <br /> CITY L 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 <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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWN ER❑ OPERAT AGER ❑ OTHER AUTHORIZED AGENT❑ <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 <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. p <br /> gwic <br /> TYPE OF SERVICE REQUESTED: CC, <br /> COMMENTS: NOV 0 <br /> ?019 <br /> i'1 Z ORONM�Co <br /> H 0EPgR MENT <br /> ACCEPTED BY: (j i_\c EMPLOYEE#: DATE: \\\(7,5\ <br /> ASSIGNED TO: mV`� h��J\ EMPLOYEE#: '�J>i�(f�\ DATE: <br /> Date Service Completed (if already completed): SERVIC✓E CODE: P I E: <br /> Fee Amount: —^ ou Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 025 �/� �/�]� SR FORM(Golden Rod) <br /> REVISEDSED 11/17/2003 r/" '' X11— �✓7� <br />