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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE R�ECUEST# <br /> 0 y <br /> OWNER/OPERATOR (00 <br /> CHECK If BILLING ADDRESS <br /> ✓'f e1,�' F'GeC i� �t� � {t- C-FJ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) t t i � <br /> F Street Num4er Street Name <br /> CITY STATE ZIP _ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> L) -( I �� - l�oo�- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> -e CHECK If BILLING ADDRESS <br /> BUSINESS NAMEl 6 7 PHONE# EXT. <br /> I ✓ecl P11c, 1.0 P" C-v rZul 'SII-f -0 ;Gl1 <br /> HOME or MAILING ADDRESS fRCx 10 FAX# <br /> CITY \1✓r.<� )..! STATE ZIP .�7 <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 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 laws. <br /> APPLICANT'S SIGNATURE: � /'' `�� DATE: <br /> PROPERTY/BUSINESS OWNER,;Lu 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 assess t information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It IS o�i 1pe Or <br /> my representative. r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> aw j 2019 <br /> h ENURE <br /> FACTjyOFPMR Jy <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: ! <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: U <br /> Fee Amount: Amount Pai �1 Payment Dates, -j <br /> Cl <br /> Payment Type Invoice# Check# Receive B v_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />