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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/OPERATOR _ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME V (N <br /> SITE ADDRESS �,� ,l � � �a D CI <br /> 'o Street Number Direction -/G- Street Name cityZI C`o'de` <br /> HOME or MAILING ADDRESS (If Different from Site Address) ��� C?��y U'2 <br /> 4 2>Z5 Street Number Street Name <br /> CITY �, I STATE ZIP <br /> L £ <br /> C-4V c/ <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> (�►Gly Ei,��AT�-T��t= <br /> BUSINESS NAME PHONE# EXT. <br /> <tx s(,4, _ ) �i -'/ �' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY v-� „1 STATE, ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned props or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRON ENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified this form. <br /> I also certify that I have prepared this application a t the wo k t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE an -'FE RAL <br /> APPLICANT'S SIGNATURE: --! DATE: <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is availab'.e and at the same time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> MAY 16 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <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 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 �vr � SR FORM(Golden Rod) <br /> 07/17/08 <br />