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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propertf FACILITY ID# SERVICE REQUEST# <br /> Ke,9,L1�11� <br /> OWNER i OPERATOR <br /> CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESSSS �J <br /> /x treet Number Dir6 i4A/jl)//'��eet Na e i ` CLd <br /> HOME or MAILING ADDRESS (If Different from Site Addre s) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# D LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTY.ACTQR / SERVICE REQUESTOR <br /> REQUESTOR A/� <br /> l CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH / T EXT. <br /> HOME or MAILING W7 ADD AX# <br /> ` ( ) <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGE ENT: 1, 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 forin. <br /> I also certify that I have prepared this application and that theor to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA n ERAL 1 ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERO OPERA OR/MANAGER—*— OTHER AUTHORIZED AGENT O I�Q� <br /> IfAPPL1CANT 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. <br /> TYPE OF SERVICE REQUESTED: Oair !ffvs l <br /> COMMENTS: <br /> z 6 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> :7^I TIA ,42TM NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 06 Amount Paid D g Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />