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SAN JOAQUIN w.:OUNTY ENVIRONMENTAL HEALTH D. .RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> aC) (z 00-)S�)-7(��r <br /> CINr\ER/OPERATOR <br /> __`J a " CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> l C� <br /> SITE ADDRESS <br /> Street Number I Direction Streit Namo .� - I Z:..r..a., <br /> HOMF Or MAILING ADDRESS If Different from Site A /,,ess) <br /> L' <L Street Number Street Name <br /> CITY STATE ZIP <br /> PIIONF#1 XT' APH# LAND USE APPLICATION# <br /> & __ <br /> PHONE#2 _ EXT. BOS DISTRICT LOCATION CODE <br /> Gr <br /> CONTRACTOR/ SERVICE REQUESTOR - - - <br /> REQUESTOR / CHECK if BILLING ADDRESS <br /> BUSINESS NAME _ PIJONEA EXT. <br /> G <br /> HOME or MAILING ADDRESS FAX# <br /> 2 ( ) <br /> CITY STATE/ ZIP <br /> oILLlNG 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, ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 1/Ca DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 9 HER 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 :nformation <br /> to 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. <br /> TYPE OF SERVICE REQUES I ED: —OD -� 1 <br /> cl C.� c-�1� QP- <br /> COMMENTS: <br /> JQ h1CSEP 14 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: +��� EMPLOYEE#: DATE: _ <br /> Date Service Completed (Ifalreadycompleted): SERVICE CODE: PIE: ; <br /> Fee Amount: c Amount Paid Payment Date <br /> Payment Type / r Invoice# Check# Received By:11 17 <br /> a <br /> r. <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> 07/17/08 <br />