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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DVARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY <br /> SITE ADDRESS <br /> dV Street Number Direction `> Street Name Ci _ Zi[ Code <br /> HOME Or MAILING ADDRESS (If Differ ant from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. tiJJ DISTRICT LOCATION CODE I <br /> ( ) J <br /> CONTRACTOR SER1710E R-EQUESTOR <br /> REQUEST012 fp�f <br /> 2 4. CHECK If BILLING ADDRESS 4..t <br /> BUSINESS NAME PHONE# EXT. <br /> ( ^ <br /> HOME Or i1fL911rI -8.5KESSo FAX <br /> CITY 1cwj STATE ZIP Q CS3 ZZ <br /> BILLING ACKNOWLEDOErtriENT: 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 appiica' n and thatthq work to be performed will be done in accordance with ali SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S. F D s. <br /> APPLICAl Tf S SIGNATURE: �. DATE: �— Z/) <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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: _ PAYMENT I <br /> COMMENTS: <br /> JUL17 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: 1527_7DATE: 7 <br /> ASSIGNED TO: 3� �f,. ' EMPLOYEE#: DATE: f <br /> Date Service Completed (if already completed): SERVICE CODE: 2Z PIE: lzr to Z <br /> Fee Amount: C> Amount Paid 2� d Payment Date 7 ��'� (!! TT6 <br /> Payment Type Invoice# Check# S'S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />