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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r1q 00 P-7 -7 TRX <br /> OWNER I OPERATOR � <br /> ('!iJ l I CHECK If BILLING AO[]RE55 <br /> FACILITY NAME '1 n \,ry- ry�? 32- S <br /> SITE ADDRESS <br /> Street Number I Direction Street Name City Z12 Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Numher Street Name <br /> CITY STATE zip <br /> PHONE ill E, APN# LAND UsE APPLICATION# <br /> tom• �� 9 crop 2 421 '2 &1 r I <br /> PRONE#2 EXT. BOS rjt <br /> LOCATION( } CfgT <br /> [C Jl <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR } CHECK if BILLING ADDRESS❑ <br /> �BUSINEss NAME ,,I/�� � PIIONE# Ext, <br /> 3 <br /> HOME or MAILING ADDRESS! FAX 9 <br /> CITvf r �� ` STATE ( J ZIP (may` 3 // <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor 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 JOAOUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL 4awS. <br /> APPLICANT'S SIGNATURE: �� r _�.J L DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPticaNT 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 andlor environmental/site assessment information <br /> to the SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same ti. ($ provided to me or <br /> my representative. C �/ 's <br /> TYPE OF SERVICE REQUESTED: VJ z f n Xje'l/ <br /> COMMENTS: p�oV Z ,p 2018 <br /> $�JOA �7 <br /> rvvlAQUIIV COU <br /> HEALrH')CPA.N7AL y <br /> ACCEPTED By: EMPLOYEE#: OATE: <br /> ASSIGNED TO: ���1 �/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ! �� P I E: <br /> �c7LC�� Fee Amount: / Amount Paid —[ I a CJ Payment Date 1 I 1)-g J j - <br /> Payment Type L, Invoice# Check# j 7� Received By: . <br /> �JAI W <br /> fW EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />