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SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH 1j,-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK <br /> If BILLING ADDRESS <br /> FACILITY NAME U v lJ <br /> La Ct w� <br /> SITE ADDRESS �jV �Jt a S f � wtv\ 5 0-63 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> J v " �� Street Number Street Name <br /> CITY STATE ZIP `� <br /> S 11, A t <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> P ONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> aV\t1,� a�� n CHECK If BILLING ADDRESS <br /> BUSINESS NAME i a�(� \\ 1 ` PHBNE# EXT. <br /> L_ -1�(D <br /> HOME or MAILING ADDRESS FAX# <br /> CITYl ,�y 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 anq FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: O I -G� <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 same tlml�{'glpyl �1�me or <br /> my representative. �+/A�►�T Mm ryry �� <br /> TYPE OF SERVICE REQUESTED: V 4M] /I <br /> COMMENTS: OCT U 1 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: \.I� EMPLOYEE DATE: 1� <br /> ASSIGNED TO: F vvv EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ) PIE: v <br /> Fee Amount: Amount Paid Payment Date �p <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />