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SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type o Buslne s or Prop�rty FACILITY IA# SERVICE REQUEST# <br /> 2�i� FA c�'7r 2 15P-00 ',-31 <br /> OWNER I OPERATOR El <br /> (;HECK If 81LLII10 ADOR_es <br /> FACILITY NAME �� otir l c <br /> r`1-nes.] �} <br /> SITE ADDRESS #Of ka1�� ' t'� lD1t GC -T 1 C e <br /> 6Slreel Nurn6et Oirecflon .r� <br /> HOME or MAILING ADDRESS (If Different from Site Address) � VVV <br /> stfeet Ham" <br /> CITY , , i„e 11 e ZIP <br /> PHONE A EXT. APN# ,rf -c APPLICATION# <br /> ( i - •22'3 <br /> PHONE#2 Ext. HOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if 61LLIN3 ADDRESS <br /> BUSINESS NAMPHONE# EXT' <br /> E <br /> �d rev �rJrt S <br /> HOME Or MAILING ADDRESS FAX# <br /> 4 ( } <br /> CITY I�Q STATE ZIP f zlo <br /> g <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 ENt moNMENTAL HEALTH DEPARTWNT hourly charges associated with this project <br /> or activity will be billed to me or my business as ideptifed 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 JOAQUrN <br /> CoUNrY Ordinance Codes,Standards,STATE and DERAL Iaw . IJ <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER© OPERATORI MANAGER CI OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign Is required Title <br /> UTHORIZATION 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 envirorunentaltsite assessment <br /> Information to the SAN JOAQUIN CouN TY E,lVIRON&MNTAL 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: k <br /> COMMENTS: "® <br /> APR302019 <br /> sA v>QIjIN COIJ <br /> N At-7N DEPAArAJEiUT <br /> ACCEPTED BY: Nr EMPLOYEE#: O NYE: (d <br /> ASSIGNED TO: EMPLOYEE#: Z�;j G W DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: `y Z PIE: ?�� <br /> . r <br /> Fee Amount: Z mount Pal �a UIQ Payment Date /���� <br /> Payment Type Invoice# Check#_ ��c1<-j`� Recai ed By:�/i��� <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />