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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH GCPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# AERVICEREQUEST# <br /> OWNER/OPERATOR /; <br /> 1 n/" I Kar <br /> �an CHECK if BILLING ADDRESS E] <br /> FACILITY NAME V(/ V `" r t <br /> SITE QADDRESS 44 Ut In Wut( r• Y U`��� ��U <br /> f�V Street Number Direction - Street Name J •1 �} Ctt Zi Code <br /> HOME OrILING ADDRESS (If Different from Site Address) <br /> 9-2)9- v <br /> Street Number Street Name <br /> CITY � $TA'�E ZIP �(��I) <br /> U (lam[l'1< <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 2P '2qU l0 7 U <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> 6 j GJD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> U � <br /> BUSINESS NAME PHONE# EXT. <br /> C0�1( aq90 -10 IA <br /> HOME or MAILING ADDRESS _ FAX# <br /> CITY C`` STATE ZIP <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: � 17 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 Tine <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 t0 me or <br /> my representative. n <br /> TYPE OF SERVICE REQUESTED: Y UV`I ( r <br /> COMMENTS: <br /> C nary ' aF 6 v��e►ASH i p DEL <br /> � g 2018 <br /> JOAQ NMCOUN <br /> �"- S�NVIRO E TjJAIE T <br /> TH DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 / <br /> ASSIGNED TO: /t EMPLOYEE#: 2 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( PIE: <br /> U/ <br /> Fee Amou t. C Amount Paid 152. Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />