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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SS J7o2-q <br /> OPER/OPERATOR <br /> SG,oCHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRES� me n� O <br /> U Street Number Direction tr t Name CiC�t� Zf ode <br /> H E Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY1 , r \\ xSTIA <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT —71 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ \Q ��`_ CHECK if BILLING ADDRESS <br /> BUSINESS NAMELof�c\cNe,,�' <br /> 1•� \(3 � a,^ ` ` PHONE EXT. <br /> ` \0 )G (✓� <br /> H M Or AILINGADDRE 5 FAX# <br /> CITY �- S , 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,STATE and FEDERAL laws. / <br /> APPLICANT'S SIG NATURE:�j—'1/ fe/l DATE: Z /;2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ 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 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 at the same time It is provided t0 me or <br /> my representative. ' '-��/IN <br /> TYPE OF SERVICE REQUESTED: w `� V RECEI�/ED <br /> COMMENTS: <br /> MAR 2 3 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: mw/I! fmq oil <br /> EMPLOYEE#: DATE: -?/"q <br /> ASSIGNED TO: ` (I/ e EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: ( PIE: 0 <br /> Fee Amount: I ✓ `I I <br /> 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 />