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i <br /> SAN JOAQU N COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ;''� <br /> r;ste y� 1/a 1—n ��_ ��� �� CHECK If BILLING ADDRES <br /> JZr FACILITY NAME t&ALo- <br /> 1' �1V���J I yr <br /> SITE ADDRESS f 1►'12_ <br /> Street Number Direction Street Name �- city-� Zii Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY L_^ STATE � ZIP <br /> PHONE#1 VC/�� EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t/�tz rsn'r--N_ C � CHECK if BILLING ADDRESS <br /> �1 T f <br /> BUSINESS NAME PHONE EXT. <br /> L�1Glo a2a 5 n _ PHO�i 3ZG1-784 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE / ZIP <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 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Y1! <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MUNAGER ❑ 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it IS provided to me Or <br /> my representative. l p <br /> TYPE OF SERVICE REQUESTED: Q S� ( 1 a-(1'�0(, O <br /> COMMENTS: 5o <br /> a y 2019 <br /> H�T►,/�H/'v��UNry <br /> EpgRT Tai <br /> ACCEPTED BY: �/�vu J- EMPLOYEE#: �3 I DATE: f_(2II /19 <br /> ASSIGNED TO: 1R-`MCC l o I on EMPLOYEE#: 3l 3 DATE: G/Zy 0 <br /> Date Service Completed (if already completed): SERVICE CODE: W 1 P I E: W 103 <br /> Fee Amount: l Sa L)—C) Amount Paid 5a 00 Payment Date <br /> Payment Type f (�t Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />