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SAN JOAQ . COUNTY ENVIRONMENTAL HEAL- JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �x l (� U <br /> OWNER/OPERATOR C-A c, CHECK If BILLING ADDRESS E]e't 0 zti7ti►.�s <br /> FACILITY NAME <br /> �VICw <br /> SITE ADDRESS1— <br /> Street Number Direction V`xvGLA-\a. <br /> et Name O�G Ci \ �Z Codev� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 01-0 ,;I- Street Number Street Name <br /> CITY kw` STATE ZIP <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> —1[– <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME \ J PHONE# EXT. <br /> HOME or MAILINADDRESS FAX# <br /> CITY c�c \_ STATE ZIP �r r <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 <br /> or 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 FEDER L laws. r �` <br /> APPLICANT'S SIGNATURE: r.,. DATE: /I- <br /> PROPERTY/BUSINESS OWNER ' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> !(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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: dJ ymica I VuWkxA^ CES <br /> COMMENTS: <br /> s,�1�o L, 1 1 2019 <br /> B AQUIN <br /> HE,gL H/DE R L <br /> Nr <br /> ACCEPTED BY: A Q EMPLOYEE M DATE: I Z <br /> ASSIGNED TO: \ 1�L G J EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(J I P I E: 1(003 <br /> Fee Amount: L .— Amount Paid +> Payment Date ( c� <br /> Payment Type U f Invoice# Check# Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />