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SAN JOAQUIN PUNTYEPARTM <br /> ENVIRONMENTAL HEALTH DENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAT <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> slAgDrtE�ss _AJ <br /> Street tion Street i ne "bra cE <br /> Street Number DirecName t Zi Code <br /> HOME or MAILING ADDRESS (If Different from S'a Address) <br /> G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> � a <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (�o�) 21 � X333 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR !�A ,7CL <br /> CHECK If BILLING ADDRESS ,A <br /> BUSINESS NAME � PHONE# EXT. <br /> 0. ► [c)co <br /> HOME or MAILING ADD ESS FAX# <br /> � tS c T ( ) <br /> CITY S�VCYJPY-\ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent ov 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, Standards,STAT nd F5�2 <br /> APPLICANT'S SIGNATURE: DATE: La /a2ZE <br /> PROPERTY/BUSINESS OWNER OPERAT R/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 I v■i�ded to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �� ms\lk, <br /> COMMENTS: <br /> �JoP062018 <br /> }AAQUIIV <br /> SN H D AdE n' <br /> NTUN <br /> OEPMTMENT <br /> ACCEPTED BY: y ow&vl o <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: V— EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 ( P/E: <br /> Fee Amount: -t(05 2.(3 Amount Paid �5 Z — Payment Date <br /> Payment Type Invoice# Check# Received By: Lit <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> QN/U �I IVU <br />