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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I ocl <br /> OWNER/OP TOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ri <br /> S+�y7/EQDD ESS //� / V t r <br /> v` Street Number Direction `i L Y� � St 1 ca `'-ft �l�I ` J <br /> reef Na e t Zi ode <br /> HOME or MAILING ADDRESS (ifDifferent from Site Address) <br /> ►' ' i` (-x1 11Street Number Street Name <br /> CITY STATE ZIP <br /> P TONE#� T AP # LAND USE APPLICATION# <br /> PHONE#2 C+f— 1T. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ) <br /> 1) CHECK If BILLING ADDRESS <br /> BUSINESS NAMEe.{' L' f��� I (.(�- G.J S� •1`� I I P(7_"_,f (0 _? E^T <br /> HOME or MAILING ADDRESS r FAX# <br /> SLa'v� J <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 preparediO <br /> ication and th the work to be perfo med will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, StandaE and FEDERA WS. <br /> APPLICANT'S SIGNATURE: DATE: �w <br /> PROPERTY/BUSINESS OWNER❑ ATOR/MANAGER J OTHER AU HORIZED AGENT El <br /> If APPLICANT is not the BILLING PARTY,proof of authorization t 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time '* provided to me or <br /> n <br /> my representative. _^ c `,NC <br /> TYPE OF SERVICE REQUESTED: "BOG `tel avn G�V�L' ( RECEIVED <br /> G <br /> COMMENTS: <br /> '1 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Y VIA o -t o EMPLOYEE#: DATE: - ijil <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:J Z 3 PIE: • w/ <br /> Fee Amount: l(S' Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />