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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE # EXT• <br />FACILITY ID # <br />FAX # <br />CITY STATE ZIP <br />SE�RV1ICE # <br />Sl -'J& <br />� " <br />AU6 U 7 2017 <br />ACCEPTED BY: <br />S <br />�R'EEQUEEST <br />00l /IC2'(. �SZ-2- <br />OWNER / OPERATQ� <br />EMPLOYEE #: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />L, eC' <br />n <br />b <br />D <br />Amount Paid I _ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Payment Type <br />Invoice # <br />Check # + I -j > <br />SITE ADDRESS <br />� � ` Ft'"` y <br />C <br />J Street Number <br />Direction <br />'" StrBlt Name <br />HOME Or MAILING ADDRESS (If DifVe/rent from Site Addfess) <br />NU <br />,C�jfyi <br />�� S rt a€t Number <br />Street <br />Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />lZc - <br />3- 3 - <br />PHONE #2 <br />( ) <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQJU "WR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT• <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />BILLING ACKNOWfEDGEMENT: 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 />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, TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 9)-7-12 <br />PROPERTY I BUSINESS OWNER ❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT 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 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 provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: lAmav <br />COMMENTS: <br />04tL <br />(7-,q, q53 - -76177 -rd Ver 4yV&V-V <br />�• 0. <br />To Q64-046, � �. rl-" <br />RECEIVED <br />AU6 U 7 2017 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DAW UIN O TY <br />DA. T ENT <br />ASSIGNED TO: <br />EMPLOYEE #: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid I _ <br />Payment Date <br />0 � 7 / <br />Payment Type <br />Invoice # <br />Check # + I -j > <br />Received By: <br />C� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />