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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br /> SERVICE REQUEST <br /> Type ofBusinessor Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �/ jq�'1 Street Number D rf ection Street Name CI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 6%A •/'� I Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2D9) g 3 311 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS O <br /> d Q C I a- <br /> BUSINESS NAME PHONE# EXT. <br /> GYMAK1-CO 2C1 y163 - 3LJW <br /> HOME or MAILING ADDRESS FAX# <br /> V - ( ) <br /> CITY 'z'-'0C C n <br /> STATE Cn ZIP s Q <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: Al Q r t r Ci'YG 1 Ct_ DATE: <br /> PROPERTY/BUSINESS OWNER E( OPERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tirie <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: <br /> COMMENTS: RECEIVED <br /> MAR 19 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Ji EMPLOYEE#: DATE: IG 4 <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: i <br /> Fee Amount: 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 />