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SAN JOAQU�COUNTY ENVIRONMENTAL HEALTH -PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# C SERVICE REQUEST# <br /> s�o 1 <br /> OWNER/OPE! <br /> TOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME _ <br /> SITE ADDRESS (^�/ , , ` f " F�c f <br /> ` n`3S .Number Direction C1fi Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) I Z f r ��7/ w <br /> l Street Number ` `` Street Name <br /> CITY \V Y-\ ST E. ZI -:xr <br /> PHONE 11 EXT. APN# LAND USE APPLICATION# <br /> PHONE ill EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME J 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 /> 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: LQ ;LA � 19 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ HER 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 aksessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same tiOP <br /> Qyided to me or <br /> my representative. 49, <br /> TYPE OF SERVICE REQUESTED: o + '`Ip <br /> COMMENTS: <br /> J , 2019 <br /> ENV/qQU/N CO <br /> y�CTH EN&At <br /> T <br /> ACCEPTED BY: EMPLOYEE#: OZ) DATE: (21/1 <br /> ASSIGNED TO: EMPLOYEE#: K� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O('a ' PIE: L/ 0 3 <br /> Fee Amount: ' Amount Pai / �� J(] Payment Date <br /> Payment Type ! Invoice# Check# ��'7 �/ Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />