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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S g-Z-cu2 <br /> J11VNERJJER11T1 01 <br /> 05 + rJ CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME r}I �r <br /> V <br /> vrA 7- <br /> ..SITE ADD S }/�� �r7`�- !r Ir (p�)(/�� <br /> CJ Street uMber Direction V V [i (�" �tYadt Nam mode + <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 �- <br /> Street Number Street Name <br /> CITY STATE zip <br /> e 4yo a 4<9; <br /> �!'-E'�) ! 2 5 ExT' APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> (L( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> I [REQUEST <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME I PH�E / EXT. <br /> 424 HOME r MAILIN AD DR 5S n(� FAx <br /> �C / ( 1 <br /> CITY I / STAT zip <br /> `1 ffL NG A KNCO^WLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agen 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 nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Sfandardr, STATE d FEDE ws: <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANA ER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPLICRNT is n e 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 /> infonnation 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. A <br /> TYPE OF SERVICE REQUESTED: , r <br /> COMMENTS: Dk-C ° <br /> N RpN N <br /> (J Cp <br /> SCF � <br /> �FNT <br /> ACCEPTED BY � EMPLOYEE#: DATE: <br /> ASSIGNED TO: �('Pv-� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0\1-k P I E: 1 ©Z <br /> Amount: . Amount Paid Payment Date 2 2L2— <br /> Feet/ <br /> • <br /> Payment Type Invoice# I Check# Received By: <br /> EHD 48-02-D25 SR FORM(Golden Rod) <br /> REVISED 11/17/2043 <br />