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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> oL S-�t o SERVICE REQUEST# <br /> C6 ��7F <br /> NERIOPER�TOR� ! CHECK IfBILLINf3ADDRESSCI <br /> vV q.,llr W 11D 1 <br /> FACILITY NAME ±treet <br /> �-�SITEADDRESS / � � �3;1 d <br /> Number Direction S teat Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHooONEE##1 �i(� LAND USE APPLICATION IIIV <br /> Ext. APN -/ qo <br /> PHONE#2 Exr, BOS DISTRICT LOCATION CODE <br /> ) ?- O <br /> ( i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> - {� ` <br /> BUSINESS NAME a t ` <br /> FAx <br /> # <br /> HOME or MAILING DRF,SS <br /> STATE ZIP <br /> �CC <br /> CITY � j S p <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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 /> 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: fZ1 g <br /> PROPERTY!BUSINESS OWNER 13OPERATOR/MANAGER 13OTHER AUTHORIZED AGENT ❑ '-el <br /> /f APPLICANT Is not the BILLING PARTY,proof of authorization to Sign 1S required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. /t <br /> TYPE OF SERVICE REQUESTED: .( ivY 0 MENT <br /> COMMENTS: <br /> CEIVED <br /> MAR 2 3 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: ,�3'/ff <br /> ASSIGNED TO: - EMPLOYEE#: DATE: 7✓._ <br /> r1 <br /> Date Service Completed (if already completed): SERVICE CODE: P.- <br /> Fee Amount: GJ ��" Amount Paid 5 Payment Date 3 Z3 <br /> Payment Type Invoice# Check# I Ll 0u Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> 67/17/08 <br />