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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> / SERVICE REQUEST <br /> Type of Business or Property FACILITY Iq# SERVICE RE UEST# <br /> tt' C v f r v C J\)C'c� �R <br /> OWNER/OPERATOR � <br /> 'J i C / ` G CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITF� ce Q Street NumberDirection " "-St�'N � r " v city �Zip CodeO� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 12 (7 Street Number V Street Name / ✓�7L <br /> CITY C� C� � � / STATE ZIP _ <br /> PHONE)1 EXT. APN#� I _ /� LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRIC LOCAT N E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> - <br /> BUSINESS NAME PHONE# EXT. <br /> e 0'pq 0'p5 a 5 <br /> HOME or MAILING ADDRESS I v FAX# <br /> ( ) <br /> CITY STATE C 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: —r�12 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 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 /> 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. <br /> TYPE OF SERVICE REQUESTED: p PAY <br /> Ir <br /> COMMENTS: <br /> JAN 01 2018 <br /> SAN JOAQUIN COUNTY <br /> F-NVINMENTAL <br /> .ALrH oEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ` Y , EMPLOYEE#: DATE: <br /> Date Service Coinplete (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: �0 Amount Paid Payment Date <br /> Payment Type C 4 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />