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SAN JOAQUIN COUNTY FNVIRONMENTAL HEALTH DEPARTMENT -"*'1 <br /> SERVICE REQUEST - I2� 0UIOS <br /> Typ�iness or Property FACILITY ID# SERVICE REQUEST# <br /> 41 1&4- <br /> 177 <br /> OWNER/OPERATOR <br /> ,- ,�/I ��� CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> ySIITE ADDRE/SS� �// <br /> ? 61.E/ Street Number Direction s r(:etZi t�mn� �'✓CI Code <br /> HOME <br /> / <br /> e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. z�A <br /> F(C <br /> PN# LAN�SE APPLICATION# <br /> (� 3�/ -74�� 5�� l z� Z5 t r ,� <br /> PHONE 92 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) OU <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR d <br /> I��v!�v -"5c.-'A-!J,9 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# - ``-xT <br /> HOLAE or MAILING AD ES. FAX# <br /> CITY 5 .�N STATEC^ 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 Ws. <br /> APPLICANT'S SIGNATURE: DATE: /U k" - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT— /< <br /> It APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Time <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 t0 me Or <br /> my representative. NT <br /> TYPE OF SERVICE REQUESTED: �` 11ccAc,11nQRECEIED <br /> COMMENTS: G <br /> (� { 0 8 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONM NTAL <br /> HEALTH DEPA TMENT/ <br /> ACCEPTED BY: EMPLOYEE#: DATE: y� <br /> ASSIGNED TO: EMPLOYEE#: DATE: x) <br /> Date Service Completed (ifalready mpleted): SERVICE CODE: P/E: u <br /> Fee Amount: OV Amount PaidC) Payment Date <br /> Payment Type Invoice# Check# �'3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />