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SAN JOAQ.,N COUNTY ENVIRONMENTAL HEALTH LoEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ,r ry� CHECK If BILLING ADDRESS <br /> I `/ <br /> FACILITY NAME <br /> rlk (A-rY�z r�da5 -� �laY'E� <br /> SITE ADDRESS <br /> t,'�i� t✓�. ':fir, �11�� S �� S�OGF��oI't ' �:��3 <br /> ( Street Number I Direction ��� \treat Name cityZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) � /t c rGs R(� <br /> Street Number Street Name <br /> CITY STATE ZIP n� 2 <br /> CA <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (HCl - N3-79 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQRE TOR 0 <br /> p 0�!?\ CHECK If BILLING ADDRESS <br /> BUSI S NAME PHONE# EXT. <br /> l ` Y A — n e <br /> HOME or MAILING ADDRESS, FAX# <br /> i gr <br /> CITY STATE n ZIP � 1 .� <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 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 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It iWrovided to me or <br /> my representative. PAY <br /> TYPE OF SERVICE REQUESTED: o ( n ECE <br /> COMMENTS: <br /> 2017 <br /> S IV N�ROjVIN COUNTY <br /> HEALTH pE ART NT <br /> ACCEPTED BY: kr, Ha Mom[) IL k 0 rh EMPLOYEE M DATE: <br /> ASSIGNED TO: /1�S I }r EMPLOYEE#: DATE: r�L.(II'� <br /> Date Service Completed (if already completed): v` SERVICE CODE: C Z P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />