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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '�3�Ob 717 q�e <br /> OWNER/OPERATOR <br /> Nyyy��� ///��� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �p `! ^ ,`� 1�I V��'1� MMM <br /> SITE ADDRESSZL� +lu '`}f-J�, ✓ LL <br /> Street Number Direction Street Name city Zio Code <br /> HOME or MAILING ADDR\ES5 C `S`(If Different from Site Address) <br /> ` V ` Street Number Street Name <br /> CITY TE ZIP <br /> k�c <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 0') -Iq '2,316 sz �- <br /> PHONE#2 - ExT• BOS DISTRICT LOCATION CODE <br /> Z' - S"z J l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# 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, STATE EDE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I/APPLICANT is not the BILLING PARTY.Proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 It Is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYM <br /> EN <br /> RECEIVE <br /> MAR 17 2015 <br /> Q&NJOAQUIN C UNTY <br /> FTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I ��� (Jt EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: Q <br /> Fee Amount: p Amount Paid ����� Payment Date <br /> Payment Type i ��� ,� Invoice# Check# Received By: �� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />