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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -a)L- i —.� LL L-L� `_J`l <br /> OWNER/OPERATOR <br /> c.,b C �t, C C- S Ei Q1 51 �-1 ` C�4`_1*—.1 CHECK if BILLING ADDRESS <br /> FACILITY NAME ✓✓✓ <br /> SITE ADDRESS W v ^r V) ��\-� �c� Tq <br /> v! Street Number Direction (� L= M1 1 Estreat Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE� 1ZIP C. c 4N- Ll <br /> PHONE#1 EXT. ApN# LAND USE APPLICATION# <br /> k�) uo(qUc� <br /> PHONE 4 <br /> 2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 57,0 9 Z 2-6 Z <br /> HOME or MAILING ADDRESS FAX# <br /> O 1 i=ce- - zoo (s)y a- q 7 3 <br /> CITY kA <br /> TATE LIP r� <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 11-�,—> ` t�w ��_ DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER �OTH R AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authoriza3ion 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. A <br /> TYPE OF SERVICE REQUESTED: l -'C I C C.1 1` `1-`_zr r Reci; e <br /> COMMENTS: <br /> AN 3 0 2018 <br /> 3 NVIR p UI N COU <br /> HEACTH O�PAR MFNry <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G ( EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed SERVICE CODE L " P 1 E: <br /> . i l U L <br /> Fee Amount: �L• r Amount PaRt!s� �� Payment Date G <br /> Payment Type Invoice# Check# ILL ReceiLed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> P�S3 els 6 s <br />