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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OIPVN R/OPERATOR <br /> CHECK If BILLING ADDRESS k� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction /vl rSltreet Name !"v`CC'i`ty' _ Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> _ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (21°') (-�('-0-/13 <br /> P(HONE#2 EXT. 130S DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> IREQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEnV�� PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 2(c� \1 f\A ( ) <br /> CITY JA N(�C� STATE ZIP S3 3 <br /> BILLII4G ACKfNOtrVLEDGErthENT: 1, 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 nd FE DEI AL laws. <br /> APPLICAIY T,S SIGNAITU - DATE: 2� <br /> PROPERTY/BUSINESS OWNER OPER TOR/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 available and at the same time It IS p j�_t0 me or <br /> my representative. <br /> I I VDE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> sqN'/o �2016 <br /> H�ALN IRpMN CpUN <br /> M 06 RT EN <br /> T <br /> ACCEP,ED BY: EMPLOYEE#: 0 v DATE: -7 ' <br /> ASSIGNED TO: ,/� EMPLOYEE#: I DATE: <br /> Date Ser•riceCompleted (if already completed)* SERVICE CODE: Z PIE: U � <br /> Fee Amount: ArrrOunt i a(p (J Payment Date '? —�- <br /> Payment Type Invoice# Check# By: <br /> i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />