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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH C tPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> n ( �! A �\ r � �'—.G� CHECK If BILLING ADDRESS <br /> FACILITY NAME �l i NSITE ADDRESS 7q5 <br /> r <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE �.� ZIP �•�� <br /> PHONE#1 EXT. APN# / LAND USE APPLICATION# <br /> (2c9) 2a-7 -7C) 1`7� / 4Pe <br /> PHONE#2 EXT. BOS DISTRj Cz\ I LOCATION 7E <br /> tel/ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> G 12 `— <br /> BUSINESS NAME - PHONE# _ EXT. <br /> c� c C c/ <br /> HOME Or MAILING ADDRESS FAX# <br /> I ( ) <br /> CITY CIO C(-I <br /> STATE ZIP 6 <br /> BILLING ACKN WLEDGEMENT: I, thlddm <br /> roperty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project spNTAL HEALTH DEPARTMENT hourly Charges associated with this project Or <br /> activity will be billed to me or my business form. <br /> I also certify that I have prepared this liwork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ATEs. <br /> APPLICANT'S SIGNATURE: DATE: / J <br /> PROPERTY I BUSINESS OWNER 013OTHER AUTHORIZED AGENT [3If APPLICANT is not the BILLING PART roof 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: LL Q <br /> COMMENTS: <br /> DEC 2 1 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: /-:2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: / "� <br /> Date Service Complete (if already completed): SERVICE CODE: G! PIE: �/ <br /> Fee Amount: G �� Amount Paid Payment Date I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />