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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> / CHECK if BILLING ADDRESS <br /> t <br /> F CILITY NAME <br /> /.. J <br /> ITE ADDRESS L �J <br /> reef Numbe Direction Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Numb¢r Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) C)(.11C_- )L)Ci <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i 1, <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING A99D,R S FAX <br /> CITY STATE ZIP <br /> C' <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. V q <br /> APPLICANT'S SIGNATURE-N C-)i /V; (LAJ C. DATE:�( / 7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 sOwided to me or <br /> my representative. F%"' 'f ' ' 1 <br /> TYPE OF SERVICE REQUESTED: -Li�� V 6 0 C J <br /> COMMENTS: SEP 0 1 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> L i 1 j� L q'*" HEALTH DEPARTMENT <br /> ACCEPTED BY: 1 EMPLOYEE M DATE: 61 - <br /> ASSIGNED TO: EMPLOYEE M DATE: Cl _ <br /> ti <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: <br /> Fee Amount: f r Amount Paid i,;_: _ f Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />