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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH u6PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# , SERVICE REQUEST## <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 9 <br /> t 1 2 <br /> SITE ADDRESS �"� /.�' /I y ICI /��lc� v/ e °` <br /> Street Number Dir ion' <br /> (� Street Name Zip <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam <br /> CITY STATE ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> c ) Ig72`1002 <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> f CONTRACTOR / SERVICE REQUESTOR <br /> RECIUESTOR t I'I`I ` CHECK if BiLLINg,ADDRES <br /> BUSINESS NAME PHo> # <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ^e Y) STATE !1� 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 appjication and that the work to be performed will be done in accordance Ttall SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, E RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I 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 tlnPA' rovlded to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: L) t <br /> COMMENTS: �JO 1 y 2018 <br /> EIy�R Q(Jlly C <br /> H1�TN Opq�MOUN 7Y <br /> T <br /> ACCEPTED BY: Q EMPLOYEE#: DATE: IL <br /> ASSIGNED <br /> CX <br /> ASSIGNED TO: EMPLOYEE M DATE: C, I ` 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:IL <br /> Fee Amount: CT Z ":L- <br /> : Amount Paid OD � 6.(� Payment Date <br /> Payment Type Invoice# Check# l>cjGG Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />