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SAN JOAw JIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDI# SERVICE REQUEST# <br /> 0 b � D) <br /> OVVF /OPERATOR <br /> L CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS S <br /> ZStreet Number Direction � ' 'StYeet ame 'DC v� ZipCode' <br /> HOME Or MAILING ADD R S (If Different from Site dress) <br /> Street Number Street Name <br /> CITY � �� � � STATE„ ZIP � r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR a CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE EXT. <br /> a 6S <br /> HOME or MAILING ADDRESS FAX# <br /> G ✓ ( ) <br /> CITY L ^ S ZIP C <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:L I Cilj�j�i ilii CMZ c% DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization to sign IS required Tile <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 to me Or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: 3 <br /> RECEIVED <br /> COMMENTS: j nsl'"—"" vel <br /> JAN 10 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (Q P/E: <br /> Fee Amount: Amount Paid Payment Date //3 U 7 <br /> Payment Type "_1 c Invoice# Check# -- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />