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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# r, ERVIG QUEST# <br /> OWNER/OPERATOR <br /> j CHECK If BILLING ADDRESS <br /> FACILITY NAfqE N <br /> SITE RESS <br /> 7 StrNumber Direction • `� � � Street KZam—e/V ( Zip Code <br /> H�E for I AILING, DDRESS (If Differe t from Site Address) <br /> Street Number Street Name <br /> ATE ZIP <br /> CI ;// x/ Lo �aJt%� �I VL, 2-- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST f� G /I <br /> �� h -V CHECK If BILLING ADDRESS <br /> BUSINESS NAME ZP # <br /> ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE r,1 Zip do <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 /> also certify that 1 have prepared this a ion and that the work to be rformed will be done in accordance with all SAN JOAOUIN <br /> COUNTY Ordinance Codes, Standards TATE,and FEDERAL laws. <br /> APPLICANT'S SIGNATURE. � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <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 provided to me Or <br /> my representative. p r <br /> TYPE OF SERVICE REQUESTED: t GLG ti � 1 <br /> COMMENTS: <br /> NOV 2 6 2018 <br /> SAN jOAQUIN COL, y <br /> FNVlRor4n,Flv <br /> HEALTH rAi <br /> ACCEPTED BY: 1aY f vl CjL EMPLOYEE#: DATE: 1 ! 't T <br /> ASSIGNED TO: NEMPLOYEE#: IDATE: 19 <br /> Date Service Completed (if alr y completed): SERVICE CODE: L P E: �,0` <br /> Fee Amount: 5` Amount Paid 4S( , --- Payment Date ! f <br /> pj- <br /> L412- <br /> Payment Type Invoice# Check# 3 3 J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> ep <br />