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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business e-A for Property FACILITY ID# SERVICE R1�E,QUEST#ao <br /> \ lT de <br /> OWNER IOPERATOR <br /> S C YC CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �C <br /> Street Number DirectionStre t ame Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY C �J'I��. on STATE C� ZIP n�/�Vq <br /> PHONE#1 J U 1 V EXT. APN# LAND USE APPLICATION# �tl L <br /> (M 5q?- <br /> PHONE i#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C', 1 ^, <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1T1PHONE# — �q EXT. <br /> HOME or MAILING ADDRESS 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 /> 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, ST and FEDERA WS <br /> APPLICANT'S SIGNATURE: DATE: G`"1 — I Z^ ' <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANA R�ffOTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT��Iis not the BILLING PARTY,proof of authorization to sign is required 7 i tic <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 V"t. 1 t is provided to me or <br /> my representative. C <br /> RECEIVED <br /> TYPE OF SERVICE REQUESTED: -yLs L <br /> COMMENTS: R 12 2019 <br /> SAN JOAQUIN COUNTY <br /> `' ENWRONMINTAL <br /> HM114 DEPARTMEW <br /> ACCEPTED BY: = EMPLOYEE#: DATE: <br /> ASSIGNED TO: �/ EMPLOYEE#: DATE: 1 �� <br /> Date Service Completed (if already completed): SERVICE CODE: D(Q P/E: lj�2 <br /> Fee Amount: i Z, Amount Paid 1Sa Payment Date t{ <br /> Payment Typ l Invoice# Check# Received By:—i-'� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />