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1 <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> t <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0?m' Tnn ar , ; 9 i <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS I <br /> FACILITY NAME <br /> SS <br /> SITEADDREJ C-�— <br /> z� (� DirS. 5�h t -Tri <br /> treet Number• ectlon Street Name Clt Zl Code 1 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> I <br /> Street Number Street Name <br /> CI sCr,VL STATE ZIP q- 6-q <br /> 7 #t <br /> PHONE#1 EXT AP # LAND USE APPLICATION# 1 <br /> (ZFh) ��� �5 v <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE a <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> 9 <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME C�.r4 PHONE <br /> 7 <br /> HOME or MAILING ADDRESSn F # <br /> LI <br /> 2. Mari s <br /> CITY STATE /Ta ZIP G� 3 <br /> tJ G 1 <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,Standards,STATE and FEDERAL Iaws. % r, 9 <br /> APPLICANT'S SIGNATURE: /jQj(jt�`� r DATE: �`��` 1 <br /> � <br /> PROPERTY/BUSINESS OWNER❑ /OPERATOR/MANAGER LY! OTHER AUTHORIZED AGENT❑ <br /> If,4PPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZA'T'ION 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/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at Le same time it is <br /> provided to me or my representative. AYIW <br /> TYPE OF SERVICE REQUESTED: -RECE1� <br /> COMMENTS: MAY 10 2019 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT- <br /> ACCEPTED BY: t--\ EMPLOYEE#: DATE: S—1 U I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: v <br /> Fee Amount: S 2 -- Amount Pal d /Sam�� Payment Date S� <br /> Payment TypeInvoice# Check# trlo�t/p Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17)1003 <br />