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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business 4r Property FACILITY ID# SERVICE REQUEST# <br /> /, G� J �-W 19 ':5—) cbl <br /> OWNER/OPERATOR l CHECK if BILLING ADDRESS❑ <br /> r� <br /> FACILITY NAM I <br /> i <br /> SITE ADDRESS <br /> Street Number Direction Ll�-- l• <br /> HOME Or MAILING AD_ RESS Diff nt from Site Address) Ntel <br /> 1 tStreet Number Na P <br /> CITY STATE/ ZIg52 <br /> ,1,? <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> c5 <br /> PHONE#2 EXT. BOS D TRICT LOCATIQN ODE <br /> ( ) L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR La-Kj CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> `Y1 PHONE# EXT. <br /> HOME Or MAILING A DRE FAX# <br /> CITY L STATE ZIP 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 1 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 FEDERL laws. 1 <br /> APPLICANT'S SIGNATURE: T-� _� DATE: l l� <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 /> 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> C RECEIVEn <br /> COMMENTS: SEP U 5 2018 <br /> SAN JOAQUIN COUNTY <br /> I ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S Z� /E.1 , : 1/ <br /> Fee Amount: �% Amount Paid Payment Date cs� C-5- l\� lJ <br /> Payment Type l� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />