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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 <br /> 200 1 O3 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME C H IC) T gO t� —T <br /> SITE ADDRESS �� <br /> Street Number Direction "" Street Name 'Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLINGADDRESSE] <br /> i BUSINESS NAME PHONE# _ EXT. <br /> t q� <br /> HOME Or! ADDRESS FAX# <br /> 1101 ( ) <br /> CITY ; 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 apKication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST7� and FEER,L IawS. <br /> APPLICANT'S SIGNATURE: � DATE: 1 IJ I ► �, <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ElOTHER AUTHORIZED AGENT C1If APPLICANT is not til .BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE IN ORMATION: 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 provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Ott { �t t <br /> COMMENTS: t <br /> I <br /> 3 2018 � <br /> NORUNMENTAL HEALTH <br /> 0[--RO. IT/SERIIACES <br /> ACCEPTED BY: f _ r> EMPLOYEE#: DATE: ( I I�+/ <br /> ASSIGNED TO: I t EMPLOYEE#: DATE: D <br /> Date Service Completed (if already Completed): SERVICE CODES 5r�•� --7P/E: aooq <br /> W4 Fee Amount: -$ W Amount Paid 13oL Payment Date GSI <br /> Payment TypeC Pc }C Invoice# Check# 3 � Received By: <br /> EHD 48-02-025 �� SR FORM(Golden Rod) <br /> 07/17/08 0 <br />