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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/rrZe 4 CHECK If BILLING ADDRESS <br />G / AA <br />FACILITY ID # <br />61� <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />ACCEPTED BY: L mph 0`/\ (/ � <br />` <br />FAX # <br />j�_C� -1qa-3 <br />OWNER / OPERATOR <br />CITY <br />C y 3STATE ZIP <br />EMPLOYEE #: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />2 <br />SITE ADDRESS S�S <br />PIE: U I <br />�Zt�rl�l2�2i�7e"'J <br />Amount Paid <br />+a (45(0pj- <br />Street Number <br />Direction <br />Street Name <br />ci <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />fir. <br />5 Street Number <br />Street Name <br />CITY <br />S -SLC 0-4 <br />STATE ZIP <br />C. <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />ATION CODE <br />E <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/rrZe 4 CHECK If BILLING ADDRESS <br />G / AA <br />BUSINESS NAME <br />J/L <br />61� <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />ACCEPTED BY: L mph 0`/\ (/ � <br />` <br />FAX # <br />EMPLOYEE M <br />CITY <br />C y 3STATE 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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �� ��1, ----�- DATE: 61 <br />PROPERTY / BUSINESS OWNER 1:1 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ SLG /✓e <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tirle <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 tim■e'� vided to me or <br />my representative. PAYIIA <br />TYPE OF SERVICE REQUESTED: --L ( F' <br />`/U C.- <br />RECEIVED <br />COMMENTS: <br />J I r.y <br />lltl� <br />AN 0 7 2018 <br />SAN JOAQUINCOUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: L mph 0`/\ (/ � <br />` <br />EMPLOYEE M <br />DATE: _ _ / S( <br />ASSIGNED TO: C' : G <br />EMPLOYEE #: <br />DATE: 7 _ /( S(v <br />Date Service Complete (if already completed): <br />SERVICE CODE: S -Z � <br />PIE: U I <br />Fee Amount: t 1 �' - <br />Amount Paid <br />+a (45(0pj- <br />Payment Date -) <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />