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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 , Y G ^ A' CHECK If BILLING ADORES <br /> FACILITY NAME U <br /> SITE ADDR S <br /> Street NumberDI eF coon ✓� reet Na `Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT' APN# �� LAND USE APPLICATION# <br /> ( > 813 I o <br /> PHONE#2 EXT. BOS DISTRICTI LOCATIO�ODE <br /> ( ) % <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ! -l� �r <br /> r I" CHECK If BILLING ADDRESS IJ <br /> BUSINESS NAMEp /E EXT. <br /> HOME or MAILING ADD ESS a FA%# <br /> CIN i�^1 / 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 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 law <br /> APPLICANT'S SIGNATURE: �- DATEE���}/::// <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER R AUTHORIZED AGEN <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is requir d vae <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is rovided to me or <br /> my representative. <br /> 'f__ - '` may., ' N� <br /> TYPE OF SERVICE REQUESTED: )� I�'f— 1 0�'Ing c-�/ t�V ��Nf ( EIVED <br /> COMMENTS: / •l <br /> 5/3/zo/g �Gr/i e� I-e-kW 60 r APR 19 2018 <br /> Sl!/ IdJff UIN COUNTY <br /> llew-eAi AVO-1 �pty/!*NS1 s"N�ORONMEN AL <br /> HATH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: l/— I _ tv <br /> ASSIGNED TO: EMPLOYEE#: DATE: 4_ —/ <br /> Date Service Completed (if already completed): SERVICECODE: PI Ea <br /> Fee Amount: Amount Paid :yaC ,,01DPayment Date (O l9 l <br /> Payment Type ck- Invoice# Check# �,� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />