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SAN JOAQU! "OUNTY ENVIRONMENTAL HEALTH 14 ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> Rv\ 4 O �QA— CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRES ��' R I��►` ���CK�I V, ��-�V� <br /> Street Number I Direction Ciba <br /> HOME or MAILING ADDRESS (If Different from Site Address_) Street Name 71Coe <br /> Street Number Street Name <br /> GIN STATE ZIP <br /> PHONE#11 Exr. APN# L.AND USE APPLICATION# <br /> P ONE#Z _ /? f EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR -- -- <br /> REQUESTOR ��py <br /> 1C � C�Q CHECK If BILLING ADDRESS f1�F <br /> BUSINESS NAME v PHONE,# EXT. <br /> HOME or MAILING ADDRESS ��^nC FAX# <br /> CITY Gr p� STATE ZIP q�1 +� <br /> BILLING ACKNOVJLEDGE6dIENT: 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 /> also certify that I have prepared this application"and.that thef work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT anp FEDER °s. <br /> APPLICANT'S SIGNATURE: /I \ 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 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: on 4ri-4-ioyi PAYMENT <br /> COMMENTS: RECEIVED <br /> Man 01"kJPJ'fL AUG 16 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete if already completed): SERVICE CODE: P/E: J <br /> Fee Amount: ' �� Amount Paid Payment Date <br /> Payment Type ,, t Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />