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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - � ba as h S 200 `�a�� <br /> OWNER/OPERAT <br /> CHECK If BILLING ADDRESS 01 <br /> FACILITY NAME <br /> SITE ADDRESS O S <br /> 7 3C 4f• Sc�. Gc S� 5{ ccV—t a t <br /> Street Number Direction Street Name City Zi C�no <br /> HOME Or MAILING ADDPFSS (If Different from Site Address) <br /> Street Number VvA Street-+lame <br /> CITY J `� STATE ZIP <br /> y CA S <br /> PHONE#1 EXT. APN# 14q LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT <br /> LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1y�� <br /> CHECK if BILLING ADDRESS ED <br /> c <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> O <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 /> 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, STA E and FED RAL laws <br /> APPLICANT'S SIGNATURE: DATE: LL <br /> PROPERTY/BUSINESS OWNERCS— OP RATOR/MANAGER N 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 time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ! C C PAYMENT <br /> COMMENTS: <br /> i ::I3 16 2016 <br /> SAN JOAC:IUIN COUN <br /> ENVIHOMENTAL <br /> HEALI H DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 1 Amount Paid Payment Date <br /> Payment Type ;� 1, Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />