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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e U(Q <br /> OWNER/OPERAT R °r <br /> t, CHECK if BILLING ADDRESS <br /> FACILITY NAME I '6 / <br /> SITE ADDRESS �q L, <br /> UStreet Number Direction` Y ` Street/NaUmVe'l.• CI Z-i/Code lL <br /> HOME or MAILING ADDRESS (if Different from Site Address) �J I n k US <br /> /� '1/^l <br /> Street umber 1 treetName <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 /> 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,S�dDERAL I WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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: I o i C E i d E p <br /> COMMENTS: <br /> JAN 0 5 2017 <br /> SSW JOAQUEN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: r CCd [EMPLOYEE#: ^� DATE: ` <br /> ASSIGNED TO: Q/� �S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: <br /> Fee Amount: 0 CSO Amount Paid y Payment Date 1 r /r, J ( 7 <br /> y <br /> Payment Type Invoice# Check# I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />