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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 ADDRESSC� <br /> FACILITY NAME l q ISCAW nM --�) n <br /> SITE ADDRESS `^ <br /> 10 � `(W' <br /> 3tree u ��� �� / d't <br /> t�Nd Gi ` l• ZI Co <br /> mber Irecttort 51 a me 1 <br /> <br /> <br /> <br /> <br /> <br /> <br /> (204) s1 -2)y1\ <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS <br /> Q / <br /> , e 4n <br /> BUSINESS NAME t ✓n /� t n PH NE' _ ExT' <br /> t j[ V <br /> <br /> c ) <br /> <br /> BILLING ACKNOWLEDGEMENT: 1, 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 appiiea6on a d that th ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S TE and F DERAL 1 <br /> i <br /> APPLICANT'S SIGNATURE: ell C DATE: 2 / ( - <br /> PROPERTY/BUSINESS OWNER 0 PERATO AGE OTHER AUTHORIZED AGENT 0 <br /> 1f APPLICANT 1S not t e Bf ,IN A pro of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO ATION: When applicable, 1, 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 ass sment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it etQ jne Or <br /> my representative. eNT <br /> TYPE OF SERVICE REQUESTED: ED <br /> COMMENTS: �rr 152017 <br /> SAIV JOA <br /> EMV/ QU1W COU <br /> NEALTi�Epr N <br /> ACCEPTED BY: � ) � L .1�, EMPLOYEE DATE: Z i S 19 <br /> ASSIGNED TO: Z S�rr� Z� EMPLOYEE#: LL DATE: Z 11S117 <br /> Date Service Completed (if already completed): SERVICE CODE: 0 6I E: W i� <br /> Fee Amount: 15 )l S9 I Amount Pa Payment Date <br /> Payment Type Invoice# Check# Rece ed By:Z <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17168 <br />