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SAN JOAQUICOUNTY ENVIRONMENTAL HEALTHEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />00 Sq- <br />COMMENTS: <br />SERVICE REQUEST # <br />�� <br />OWNER / OPERATORS JAL Z bb2� <br />V JJ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Coi/ <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />SITE ADDRESS L f 7 <br />Street Number <br />Direction <br />Dv�' VIN <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />DATE: <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE W <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />BUSINESS NAME _ _ _ I PHONE# <br />HOME or MAILING ADDRESS 1 11 , A I FAX# <br />CITY r W STATE <br />CHECK if BILLING ADDRESS <br />►® <br />ZIP <br />EXT. <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, Standards, STATE <br />T T and FEDERAL laws. 9 <br />APPLICANT'S SIGNATURE: / __— DATE: _ J I Z -O % <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT R L ti 5 <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. <br />TYPE OF SERVICE REQUESTED: UST w o V <br />COMMENTS: <br />REqv®& JAN 212018 <br />JIJL 10 c 018 <br />PFR NIyFAIr N <br />MITisER�CF�rH <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTED BY:n <br />l <br />EMPLOYEE M C� �� i ENT <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already comple <br />SERVICE CODE: 3 <br />PIE: J 3a <br />Fee Amount: <br />Amount Paid <br />GZ __ <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # -� d <br />Received By: Nt) . <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />