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SAN JOAQt,Ii4 COUNTY ENVIRONMENTAL HEALTH41PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �C9oc� 1 f ✓ c S �-M-79 c/ � <br /> OWNER/OPERATOR <br /> - CHECK If BILLING ADDRESS <br /> CA. S74 <br /> FACILITY NAME ` <br /> SITE ADDRESS S (/ C �/iy <br /> Street Number Diraction `�1 �rs edt NaliTe � C Zi C dve <br /> HOME or MAILING ADDRESS (if Different from Site.A�}ddress) l/ <br /> 3U L.-- :,,aGi 4�* l'o <br /> , <br /> A � Street Number Street Nam <br /> CITY Lod ,, <br /> �(/ STATE ZIP <br /> (_ � 1 2 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> o <br /> 4 mo <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) S^ 0- (') IC <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME (' PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY , ^G) (' STATE, ZIP Cs Z <br /> yo <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 d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> _i, �. DATE: <br /> PROPERTY/BUSINESS OWNER Ltl OPER OR/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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is Y&vided to me or <br /> my representative. I'+� <br /> TYPE OF SERVICE REQUESTED: "w <br /> COMMENTS: <br /> wv 2018 <br /> L,y�N�Ro���8�HOFAgT�' <br /> N <br /> ACCEPTED BY: EMPLOYEE#: DATE: �- <br /> ASSIGNED TO: G EMPLOYEE#: DATE: —7 <br /> Date Service Completed (if already completed): SERVICE CODE: ' P 1 E: 3 <br /> Fee Amount: '1 Co Amount Paid Payment Date <br /> Payment Type o� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />