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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .2C-'�U`��. Alrf ':-�kc677 S L <br /> OWNER I OPERATOR <br /> CHECK If BILLING AODRE55O <br /> S '41V-1n5 <br /> FACILITY NAME <br /> SITE ADDRESS W / 1 1417[=-7G� CC'S33 ) - <br /> Sd 4-1 %sz� ,P v� <br /> Street Number Direction reef Name city <br /> / ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) a�s /y/OORQyR K �v-G s:4 11C7 <br /> f++ Street Number Street Name <br /> CITY STATE (-A ZIP � <br /> PHONE#1 EIT. APN# LAND USE APPLICATION# S <br /> 33 $93s 19 01 <br /> PHONE#2 Etr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM`EY\�• ` PHONE# �^ 3 E>T' <br /> rh S <br /> HO E Or MAILING ADDRESS / jl FAX# ) <br /> L ll <br /> CITY C —/d _` STATE LA <br /> ZIP /Ts/ <br /> 4 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagent 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 /> 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 F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR//AANAGER ❑ 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 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. <br /> TYPE OF SERVICE REQUESTED: 2c-2O� AYMENT <br /> COMMENTS: I d <br /> �e c)V)III MAY 302017 <br /> S NJOAQUENVIROWM COU <br /> Nry <br /> HEA<T71 WrkL <br /> EA4.R7VENT <br /> ACCEPTED BY; II -- EMPLOYEE#: DATE: <br /> V I PR I <br /> ASSIGNED TO: EMPLOYEE M DATE:S �O <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: — Amount Pai13q')D Payment Date S3U <br /> Payment Type / Invoice# Check# `� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />