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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> '� o I <br /> SITE ADD SS <br /> I'�o <br /> vStreet Number I Direction <br /> HOME Or MAILI G ADDRES$'(AI,Diff rent fir mSite dress) <br /> V ( Street Number Street Name <br /> CIJa �� O� STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> 15(6 ) �� - 1I4--)j WD-0 <br /> PH 2qD / EXTBOS D6TU LOCDE <br /> ( <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME YZt PHONE# EXT. <br /> HOME or M IL GAD RE S FAX It <br /> l I ) <br /> CITY 4kh�o STATE! 1k ZIP j c) <br /> BILLING ACKN WLEDGEMENT: 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 edned will be done in accordant with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, and FEDERAL aws. <br /> APPLICANT'S SIGNATURE. E: <br /> PROPERTY/BUSINESS OWNER PERATOR I MANAG _OTHER AGENT ❑ <br /> If APPLICANT IS IT e BILLING PARTY,proof of authorization to sign IS required Tire <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 information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It Is pr (t0 me Or <br /> my.representative. <br /> TYPE OF SERVICE REQUESTED: ,Gi O e/ <br /> COMMENTS: 28—7 �INJ a 2018 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (Already completed): SERVICE CODE: P/E: l <br /> Fee Amount: I�a Amount Paid � '? Payment Date <br /> Payment Type �lu.� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />