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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - 5�P DO-737969' <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �:, <br /> _Street Number Direction `--'T Street Name Cit- JZi Codev <br /> HOME Or MAILING <br /> }A�DDRESS f Differrent from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> o E#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. I BOS DISTRICT LOCATION CODE <br /> ( ) <br /> ONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> I BUSINESS NAM �z c) PONE# <br /> HOME LI ADDRESS FAX# <br /> CITY STATE ZIP r` <br /> E31OWLEDGEMENT: 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 •vill be billed to me or my business as identified on this form. <br /> I also certify J at I have prepared this p lication and hat work to be performed will be done in accordance with all SAN JOAQUIN <br /> i;OUNTY Ordinance Codes, Standards, S E and rtEDE L laws. <br /> APPLICANT'S SIGNATURE: � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER ❑ OTHER AUTHORIZED AGENT 13 <br /> /f APPLtCAiJT IS not the BILLING PARTY, roo 'of aut rization 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: /�� V ,�(,�e_ 1�'( ( PARI -TENT' <br /> COMMENTS: 1 ^ <br /> DEC-21 2015 <br /> SAN 9ft Mull <br /> ENVI <br /> �Ep ENT <br /> ACCEPTED BY — EMPLOYEE#: DATE: p– <br /> ASSIGNED TO: EMPLOYEE#; DATE: It <br /> Owl <br /> Date Service Completed (if already complete ): SERVICE CODE: Pl l E: ucr3 <br /> Fee Amount: (-�D U?� 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 />