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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pr erty FACILITY ID# SERVICE REQUEST# <br /> » O6 Z©'-I�l� ��d2eb7y�los <br /> Q NE /OPERATOR� <br /> / / CHECK If BILLING ADDRESS <br /> ACI <br /> rCl5oh Street Name cityZi Code <br /> H ME Or MAILING ADDRESS (If D' erem fro 'te Address) <br /> Street Number Street Name <br /> CITY STATE ZIP 7� <br /> PHONE#1 EXT' APN# LAND USE APPLICATION III C— <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTY41ICTOR/ SERVICE REQUESTOR <br /> RECIU OR <br /> CHECK If BILLING ADDRESS El <br /> BUS ESSNAME - 'PHONE# EXT. <br /> Iqcama q ,e <br /> MHOME O MAILING ADDER � /� FAX# - <br /> �'— 6 ( ) <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 apation and that the work t e p rformed will be done in accordance ith all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard TATE and FEDERAL laws. t <br /> APPLICANT'S SIGNATURE. DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization t0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property Iocated 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: f7bcd PAYMENT <br /> COMMENTS: R IEC�I V E C) <br /> W 0 4 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: .. ,,rr EMPLOYEE#: DATE: 11 Ito <br /> ASSIGNED TO: 6hrL',r.I/t(, �L EMPLOYEE#: DATE: <br /> -Date Service Completed (ifalready Completed): 1� SERVICE CODE: - PL4: <br /> Fee Amount: .C7[) Amount Paid I 30, © C� Payment Date <br /> Payment TypeInvoice# Check# Received By: <br /> C13 7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />