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6 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID P SERVICE REQUEST# <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRE5SCI <br /> FACILITY NAME <br /> SITE ADDRESS �Q` '/ 2s tr qS <br /> Street Number blrection Street Name C{ Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S S <br /> v <br /> Street Number Street Name <br /> CITY � � ` A1J,� Zip <br /> PlioG"JE)i ��G EXT. APN# � J I LAND USE APPLICATION# <br /> C" <br /> Piiow#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTO/R/SERVICE REQUESTOR <br /> REQUESTOR� e� /'ter r�' CHECK if BILLING ADDRESS 0 <br /> PrION EXT. <br /> BUSINESS NAME l t <br /> HOME or MA1r=ING�ADD gESS j fax# D <br /> CITY E ZIP <br /> Y07 A <br /> BILLING ACKN LEDGEMENT: 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 wili be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and th work to be p rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ATE and FEDER9laws. <br /> APPLICANT'S SIGNATURE: d,�Gv DATE:Yi <br /> PROPERTY I BUSINESS OWNER rte. OPERAT / N G R ❑ll OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PA TY,prthorizafion to sign is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, he, authorize the release of any and all results, geotechnical data and/or environmental/site Sassessment information <br /> to tho SAN JOAQUIN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and P Tit is provided to me or <br /> my representative. r% D <br /> EIVE <br /> G _ <br /> _._ r1 <br /> i <br /> TYPE Or SERVICE REQUESTED: <br /> t <br /> CCMMENTS: MA <br /> R I Z 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> I <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE YE: 0U2� DATE: <br /> ASSIGNEDTC: ENIPLO'YEE#: Do36 DATE: <br /> Cate Service Completed (if already completed): --7Pt E: q10 <br /> L.- <br /> Fee Amount: j SLdO Amount Paid ( Payment Date 3 �-a <br /> Payment TypeC' / Invoice# 3©�6 Check# ( Received By: <br /> I EHD 48.02-025 SR FORM(fi6lden Rod) <br /> 1-7117,108 <br />