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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SER UEST <br /> F A OLO-D ;LT <br /> Iq <br /> OWNER/OPERATOR <br /> a CHECK If BILLING ADDRESS <br /> FACILITY NAME L01 <br /> SIT RESS <br /> Street Number Direction 'Street Name Z ✓ <br /> HOME Or MAILING ADDRES (If Different from Site Address) <br /> Street Number Street Name <br /> CITY ��fl ^ STA E ZIP /,j n I/\' <br /> PHON/E�#1 f 1 EXT. ApN# LAND USE APPLICATION# t/l v1i`V <br /> (4W) ( I <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEPTQR <br /> I\VI' /';� d'/l CHECK If BILLING ADDRESS <br /> BUSINESSNAME l lome n pH E _ EXT. <br /> HOME or MAILING AD RIr ; FAX# <br /> Lj ( ) <br /> CITY C /A ST T 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, Standard , ATE and FE RAL laws. r A <br /> APPLICANT'S SIGNATURE: DATE: ") <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 @i Ion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It`� qV[� Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: M 12 2019 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: /) DATE: <br /> ASSIGNED TO: / O EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pieted): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date / / 2— <br /> Payment Type%v_ _ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />