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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property F ILITY ID# RVIC REQUEST# <br /> OWNER/OPERATOR t <br /> CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME <br /> L lot e <br /> SITE ADDRESS V 15> <br /> F <br /> '' 11 O <br /> �t Pt <br /> C },5 IN l� Street Number I Direction Street Name Cit t Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 6U S.I. ' APT -3 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1�11CO I- ,Z - v L 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> (J 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 /> 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 DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> PROPERTY/BUSINESS OWNER❑ OPE ATOR/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 assessrIPAY E*T <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS p"vj jd D <br /> my representative. C CSN <br /> TYPE OF SERVICE REQUESTED: JUN 18 2019 <br /> COMMENTS: <br /> e� G VKaro�J 1 �I�p r! �flv SAN JOAQUIN COiJNTY <br /> ENVIRONMENTNL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ��T�tC�S EMPLOYEE#: DATE: <br /> ASSIGNED TO: S� A (C"aj EMPLOYEE#: DAT / <br /> Date Service Completed (if already complleted). SERVICE CODE: P I E. 2— <br /> Fee Amount: (j Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> { �-5 -5 ,� <br />