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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OLNNEP/E}PERA�R - __— - <br /> - Jo ._ - - - — — ---- -- -C7iECK!7CIL_!IVGADDP,ESS <br /> FACILITY ftI ,�J Cvr�%Vr�{J <br /> SITE ADDS SS I <br /> y Strce'Number Dirt tionStraet Nan. w ,R_,-�. � '" r_•1„ ��..r,.a.. <br /> HOME or MAILING ADDRESS (If Different from Site Address <br /> Street Number I Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APNI€' LAND USE APPLICATION# <br /> Cs 'Q <br /> PHONE#2 EXT. SOS DISTFICT � tORATION CODE <br /> L <br /> —�— - - -- — -.-.—.li_ --------' <br /> REQUE,TOR/� �'�I - --+—. <br /> ll '�'- f 111/ �i�("�. j ,\ h\ <br /> ! CHECK if-BILLING ADDRESS I <br /> BUSINESS NAME t� 1" l Yv¢, { �l PHONE# EXT. <br /> Hoor M ING ADDRESS FAX# <br /> Tu-CITY STATE ZIP �J <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 a pli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN I Y Ordinance Codes, Standards, TA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I DATE: <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 pruperty 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SEP-2 0 2016 <br /> SAN j04ULJIN COON I Y <br /> _NTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: �e-,- EMPLOYEE#: DATE: <br /> ASSIGNED TO: /jl/ G �/ pLY/t /1/, EMPLOYEE#: DATE: C� -2- <br /> Date Service Completed (if already completed): SERVICE CODE: t E: L <br /> Fee Amount_ Amount Paid -7e, PaymE:;:.Di to <br /> Payment Type S Invoice# Check.# Peceived By: <br /> s s <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />