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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE E T# <br /> OWNER/OPERATOR <br /> - CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS J1 Z lK G S ^, 1-o 4,5-LO Z <br /> /Street Number I Direction Street Name F "CityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Z 1 Ct i e" <br /> Street Number Street Name <br /> CITY O ,//1' ST TE ZIP�� 70 <br /> PHONE#1 y V EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT� I LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR S-- <br /> �/ CHECK If BILLING ADDRES <br /> —4 <br /> BUSINESS NAMEPHONE# EXT. <br /> S e to �•� S><�c y� S ` 7 3 e<:— <br /> HOME or MAILING ADDRESS J FAX# <br /> CITY 1 'd I� STATE ZIP '!F,� '7�) <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,StandardDERALL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER M� 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 assess ent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as It IS available and at the Same time It ISqpe Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: l:sDu <br /> COMMENTS: <br /> �� liuly � 2018 <br /> Ex� fyti r,QUI co <br /> hIEACoO�lyp LTY <br /> ACCEPTED BY: I1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: �I O (—k4Z_ EMPLOYEE#: DATE: > <br /> Date Service Completed (if already completed): SERVICE CODE: 7, PIE: , () <br /> Fee Amount: (P��� Amount Paid' Payment Date T �� <br /> Payment Type ��� Invoice# Check# ,%? Rec Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />