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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business orProperty FACILITY ID# SERVICE REQUEST# <br /> �o ,T �� � Sabo ► <br /> OW ER/OPERATOR <br /> Y r1 01 1 CHECK If BILLING ADDRESS <br /> Owr <br /> FACILITY NAME <br /> 1 V` <br /> SITE ADDRESS <br /> (; Street Number Direction Street Name Ci Zi Code <br /> HOM Or MAILING ADDRESS (If pifferent from Site Address) <br /> Street Number Street Name <br /> CITY STATE IP <br /> J <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS <br /> •i � cJ4� ( S <br /> BUSINESS NAME J /, / ,k PHONE# EXT. <br /> Ho7or M ILINGADD S FAX# <br /> &[& S <br /> CITY5-to .�U STATE � ZIP <br /> I � vv <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�hat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE a FAD AL laws. <br /> APPLICANT'S SIGNATURE:-, DATE: ?J <br /> PROPERTY/BUSINESS OWNER OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> Ii APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirle <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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ) I)QTUC MCC)< ED <br /> COMMENTS: <br /> JUN 2 5 2019 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: 1 EMPLOYEE#: U DATE: (0 <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: '2 PIE: <br /> Fee Amount: 99Amount Paid — Payment Date <br /> �(J <br /> Payment Type Invoice# Gheek# L/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />