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SAN JOAQUIN -..OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Caler 1 rc, lc r <br /> OWNER/OP RATOR <br /> I C -P,-) CHECK If BILLING ADDRESS <br /> -12 Ll <br /> (Z ikir <br /> FACILITY NAME <br /> b <br /> SITE ADDRESS <br /> ';4 <br /> 6--o <br /> D t � i I, <br /> Street Number Direction tree[Name CI Zi Code <br /> HO E Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ^ ZIP C�� <br /> C J (• <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> QC'cOi) -1 Ci-7—W L C. <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) �� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C--)��n-&c, C) l I 1�,t lolt ct , CHECK If BILLING ADDRESS <br /> BUSINESS NAME i `•t I '� PHIONNE# EXT. <br /> e n - <br /> HOME or MAILING ADDRESS FAX# <br /> G I ( ) <br /> CITYC l C $TATE _ ZIP Z 32- <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, S ATE a J FE RAL laws. <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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. w. ed to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 3 2018 <br /> FN�gQlgN <br /> y��TH DEpgRUN??- <br /> T <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <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 />