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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR /,1 <br /> /V 6 6� 1�1n/ t� ro ` CHECK if BILLING ADDRESS O <br /> FACILITY NAM ((tel ��C�lo1 J <br /> SITE ADDRESS (//► Ij J/ o <br /> /�StX'Number Direction( ` 2 S(/)�treet Name �� 05Zf Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) `�>' �6114 yA <br /> L Street Number ��� t�+�ig�t Name <br /> CITY S.TATTE ZI <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> ,) Z G 6 2 <br /> PHONE#2 EXT. BOS DISTRICT T70t4n, <br /> N CODE <br /> ( ► 014 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 0n1( (ab, CHECK If BILLING ADDRESS <br /> BUSINESS NAME PUQNE# EXTPdc� L • <br /> Hom or MAll-ImpA DRESS FAX# <br /> &&o) 7 <br /> CITY AI <br /> V-�j� 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 <br /> or 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,Standar"'STE and FfED-EP�A_L laws. J <br /> APPLICANT'S SIGNATURE: !Gt.�C. 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 Otle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and oje;el��rvfrironmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is vaiT"batt a same time it is <br /> provided to me or my representative. 9 <br /> TYPE OF SERVICE REQUESTED: COIII 4i� avl <br /> COMMENTS: <br /> 2018 <br /> c,vPnqe- O O-Wyl Q✓-,- S NV RAN IN CpUNTY <br /> 't EACTH pFPgR MEL <br /> ACCEPTED BY: EMPLOYEE#: DATE: y <br /> ASSIGNED TO: L EMPLOYEE#: DATE: �Q <br /> Date Service Completed (if already com eted): SERVICE CODE: P' E: 6 wZ <br /> Fee Amount: Z Amount Pai O Payment Date1-1511Y <br /> Payment Type Invoice# Check#12 106D) a-I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (� G� <br />