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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> r(AMIV �.`� CHECK If BILLING ADDRESS El <br /> FACILITY NAME a ot S (C _^D <br /> v- <br /> SITE ADDRESS �;/ � ( �` <br /> Street Number Direction Street Name c1tv Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 1f[�/{��/ /_,{ <br /> ,- Street Number )"1 li a3treet Name v 1 r <br /> CITY j ,r ' S ATE , I� C-J <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2A-71 Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> n � CHECK If BILLING ADDRESS <br /> BUSINESS NAME �„ r ` P 0. I ExT, <br /> c� v(— GhGtrri-�—C� L' <br /> HOME Or MAILING AgDRESS FAX# <br /> CITY j ' I -STATE zm. O <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, Standard E and FEDERAL la <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 It IS available and at the same time It IS provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ,--T)0 C V 1 G Iaq, (3}� <br /> COMMENTS: APR '10 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: // EMPLOYEE#: DATE: <br /> ASSIGNED TO: F 1/I/� EMPLOYEE#: DATE: <br /> Date Service Completed/ (if already Completed): SERVICE CODE: O lPI P/E: I ��• <br /> Fee Amount: / I 01 1 Amount Paid 1 -2,q Payment Date �- 1 r 1-1 <br /> Payment Type 1 Invoice# Check# Received By: ?tom <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />