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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH E cPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR A <br /> {�-�/Y�Y^1 V t J ���, Vi CHECK if BILLING ADDRESS E] <br /> FACILITY NAME ���r 1 ^1 <br /> SITE ADDRESS <br /> Street Number Direction Street Name Cit Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 23 G <br /> Street Number Street Name <br /> CITY <br /> STATE nll� ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# 1 V <br /> QD'l L-ISL-I- g-2)2S <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> Moya U -�'�/'1 c�cA Y-1cl h e, CHECK if BILLING ADDRESS E] <br /> BUSINESS NAMEC& 1 ��h' G PH # �T <br /> HOME or MAILING ADDRESS 1 ` FAX# <br /> L ( ) <br /> CITY L �j/L, r 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 F �rDERAL laws. <br /> APPLICANT'S SIGNATURE: / - DATE:C/" lG — <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTH T ZED AGENT ❑ <br /> If APPLICANT768t 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same timeIded to me or <br /> my representative. 101*1T <br /> TYPE OF SERVICE REQUESTED: _e C,1 � I <br /> COMMENTS: 2019 <br /> "NV,/ Q�/N <br /> �ARrQNT <br /> ACCEPTED BY: y l y `otCe'v l V EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C7 2 PIE: V I <br /> Fee Amount: 4 y �c-W UAmount Paid Payment Date) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />