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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 f OPERATOR <br /> N/ ` CHECK If BILLING ADDRESS <br /> F—L <br /> FACILITY NAME <br /> L <br /> SITE ADDRESS -71"7 / S l R 1 O�� ckT-o�l gSroLo y <br /> Street Number Direction Street Name J Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) //-5-o D W13/4AI 5/- VP <br /> Street Number Street Name <br /> CITY STATE - ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1. <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME � PHONE# Q .. � EXT. <br /> HOME or MAILING AD RESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 lication an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards T TE and F laws. <br /> APPLICANT'S SIGNATURE: DATE; S <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of a thorization 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 as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: myr <br /> COMMENTS: MAR <br /> �Joa 2019 <br /> E^�ROU COUN <br /> NF-ALTH p�PMS/O-AL �l <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid �-2,o4 ,CIE) Payment Date vs- <br /> Payment <br /> 5Payment Type 01 eek Invoice# Check# ���-1 Received By:� <br /> 7-T <br /> EHD 48-02-025 / S [a A 4 <br /> 9 <br /> 07/17!08 ', SR FORM(Golden Rod) <br /> � 1 _ <br /> IU �-{ I ti <br />