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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />,Tvne of Business or Property <br />ra rQ <br />BUSINESS NAME <br />FACILITY ID # <br />'N <br />SERVICE REQUEST <br />SZ C-6"77U�? <br />OWNER / OPERATOR <br />S <br />VI. -GI <br />1l C CHECK If BILLING ADDRESS <br />FACILITY NAME \ , _ <br />I,, / (1 _ <br />CT-"• lX��r� <br />Ut <br />V-,) L� �� <br />SITE ADDRESS N <br />Street Number <br />Direction <br />SAN JOAQUIN COUNTY <br />Street Name <br />CI <br />ZI ode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Ems' <br />o) 372 _0 Z <br />APN # <br />ASSIGNED TO: <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />/ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # En' <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY STATE zip <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 and FEDERAL laws. pp z <br />APPLICANT'S SIGNATURE: DATE: J Z3 <br />PROPERTYI BUSINESS QWNE OPERATOR/MANAGER—y`QTHER AUTHORIZED AGENT ❑ <br />If APPLICA T IS not the BILLING PARTY proof of authorization to sign is 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 />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 REQUESTED: - <br />PAYMENT <br />��-� <br />COMMENTS: <br />RZICEIVE <br />MAIL 41 2017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:/'' <br />vt,t- <br />DATE: <br />L- <br />ASSIGNED TO: <br />j1 A' ,�,/� <br />EMPLOYEE #: <br />/ <br />DATE: <br />t <br />I <br />Date Service COmpl ted (if already completed): U <br />SERVICE CODE: Mq <br />P/ Q <br />Fee Amount: <br />Amount Paid <br />3� b V <br />Payment Date �/2 r 7 <br />Payment Type C` <br />Invoice # <br />Check # <br />Received By: <br />0 \�-- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />