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SAN JOAQU... COUNTY ENVIRONMENTAL HEALTH L- ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# [---SERVICE REQUEST# <br /> ` 11 �` �ro cru <br /> OWNER/OPERATOR .} <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME J�� o <br /> u a V--e Z <br /> SITE ADDRESS 1(.0 Ej 3 N <br /> Street Number I Direction Street Name city �i13 Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 ExT. APN# LAND USE APPLICATION# <br /> W60 yp 3— 5 5 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORnol V re <br /> I� 11 CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 5 <br /> N. C-Scalcrl <br /> CITY tit nd-Q--r) STATE e ZIP q5 2-3& <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. Q� <br /> aDATE:/-/ <br /> APPLICANT'S SIGNATOR-E/: L <br /> PROPERTY/BUSINESS OWNER Lam, OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tire <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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: MWVT <br /> 'W16.1 VIr <br /> COMMENTS: <br /> APR 3 0 2018 <br /> EAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 116ALTH 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: Amount Paid Payment Date y 3C) g <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />