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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />hv�NVi`1� ���J alt <br />BUSINE$ AME <br />U) 00 <br />OWNER / OPERATOR <br />1 <br />s �c� <br />2 a e Irb�� <br />CHECK If BILLING ADDRESS <br />FAC TY NAME <br />I n ' LA n IC ; Cit n <br />FAX# <br />SITE ADD SS <br />C <br />CITY <br />STATE ZIP <br />"AR <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zh3 Code <br />HOME Or MAILING ADDRE S (Ify Differ nt from Site Address) <br />U0Ner; (LStreet <br />Number <br />Street Name <br />CITYfIo ` f r) <br />J J <br />STATE �; ZIP „,, � <br />(� <br />PHONE#� EXT. <br />APN# <br />LAND USE APPLICATION # <br />o Z <br />ACCEPTED BY: <br />PHONE #2 EXT. <br />( ) <br />DATE: ( � t <br />ASSIGNED TO: v� <br />BIDS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />RElzQUESTOR <br />•. <br />BILLING ACKNOWLEDGEMENT: I, the undersigned propert <br />,� <br />`I /, 1 r. \ C 1�r. f� , S•r CHECK If BILLING ADDRESS <br />n�t� <br />�,� <br />l { �l IJ 1 1 (j a <br />BUSINE$ AME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />1 <br />FAX# <br />C <br />CITY <br />STATE ZIP <br />y or buiness owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH D PARTMENT hourly Charges associated with this project or <br />activity will be billed to me or my business/as i ntifi1. o this form. <br />I also certify that I have prepared this/ p licati n and tl�` the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,14TArE a F�OERi4 laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY i BUSINESS OWNER LlOPERATOR <br />If APPLICANT Is not the BILLINGP4 <br />'N / DATE: <br />AUTHORIZATION TO RELEASE INFORMATION: <br />NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />of of authorization to sign is required Title <br />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 to me Or <br />my representative. 9ft C: <br />TYPE OF SERVICE REQUESTED; <br />Ily.r� <br />ANT <br />COMMENTS: <br />C <br />"AR <br />2019 <br />SAN JOAQUIN COUN Tv <br />ENVIRONMENTAL <br />HEALTH DEPART <br />ACCEPTED BY: <br />EMPLOYEE M fj' �� <br />DATE: ( � t <br />ASSIGNED TO: v� <br />Gl <br />EMPLOYEE #:' <br />DATE: 3/ <br />Date Service Completed (if <br />already completed): <br />SERVICE CODE: <br />P / E: G <br />Fee Amount: ®' <br />Amount <br />Paid ( <br />Payment Date <br />Payment Typ <br />Invoice # <br />Check # 1g� <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />