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SAN JOAQUI UNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />FAX # <br />CITY STATE ZIP <br />ENVIRONMENTAL <br />OWNER / OPERATOR �. 1 <br />PVA ®,C cgL_tP® i4 LC � ✓, CHECK if BILLING ADDRESS <br />✓ /1 T <br />FACILITY NAME <br />>� AST(5 <br />SITE ADDRESS <br />DATE: <br />541 ,t- ,r <br />l <br />�SZ`I l "'9 <br />is 3 Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Payment Date <br />y� <br />0 V ®)e 2 , l <br />Street NumberT <br />Street Name <br />C <br />STATE ZIP�1 '7572-"P,C�T <br />� <br />PHONE #1 EXT. <br />() 333- 510 0 <br />APN # LAND USE APPLICATION # <br />PHONE #Z EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE i' <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <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 <br />or 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 E and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: �', ! <br />PROPERTY/ BUSINESS OWNER❑ PERATOR /MANAGER OTHER AUTHORIZED AGENT ❑ M al,4wg11 <br />If 'APPLICAA'T 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JUN 0 9 2017 <br />ENVIRONMENTAL <br />PERMITISERVICES <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 �� `� <br />