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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Z- t'J �5+p 2e F�4 Ob,)- '5K06-7 9-5t5, <br /> OWNER I OPERATOR <br /> �• � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 1 V � V11� nl b <br /> SITE ADDRESS � <br /> 1 5 V 7 U Street Number Direction r I !' l Street Name e] lr Cit l Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)(/ -S+� Street Number r l Street Nam <br /> CITY ) 1 TATE Z��0 3 <br /> -S -f-a c-FV--11--L.al,, , <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE»2 EXT. BOS DISTRCATION CODE <br /> I T LO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRES <br /> BUSINESS NAME \ PHONE# E.T. <br /> vtvt Gc IJ U �,?- q kj q <br /> HOME or MAILING ADDRES FAX# <br /> CITY �5JD GX— r, STATE ZIP U <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 1 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,7TAT�FEDERAIL laws. �j- <br /> APPLICANT'S SIGNATURE: DATE: O l <br /> PROPERTY/BUSINESS OWNEI OPE AOR ANAGER El OTHER AUTHORIZED AGENT El <br /> If APPLicAN IT S not the BILLING PARTY,proof of authorization to sign is required Tifie <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: ��w� ) Y lxL — PAYMENT <br /> COMMENTS: RECEIVED <br /> AUG 2 7 2018 <br /> I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: ��, EMPLOYEE#: DATE: <br /> LCA <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5 2 PIE: <br /> Fee Amount: & Amount Paid �gC� - OU Payment Date 27 g <br /> Payment Type i ', Invoice# Check# a ( L"S- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 { G� <br /> �� 1 <br /> P�U538��1 � <br />