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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> �ro a .S 3 <br /> OWNER/OPERATOR <br /> i CHECK if BILLING ADDRESS <br /> FACILITY NME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAIL[ G ADDRESS (If Different from Site Address) �/jJ <br /> �et Numb ,F Street Name <br /> CITY STATE /7 ZIP J <br /> PHONE 1 ExT TAPN# LAND USE APPLICATION# <br /> (, . '> <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> JCHECK If BILLING ADDRESS E] <br /> BUSINESS NAME � ' I PHONE# EXT, <br /> yla <br /> HOME r AI GADDRESS ,lL FAX# (_AI <br /> 5- v YZ ( ) <br /> CITE ; 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 and FEDERAL laws. <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 7 ifle <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 ass <br /> information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time 1 �t0 me or <br /> my representative. A pr <br /> F V <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: %JOAQUI 2019 <br /> N�CTy DPgR ��TY <br /> T <br /> ACCEPTED BY: Law(-63 Q�� EMPLOYEE#: O�J� DATE: <br /> ASSIGNED TO: r� 1/bo EMPLOYEE#: �j3✓ DATE: /C <br /> Date Service Completed (if already completed): SERVICE✓CODE: G22 PI : <br /> J I /E wi <br /> Fee Amount: 5� 00 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />