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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property -400u4, FACILITY ID# SERVICE REQUEST# <br /> 1� ip <br /> co1019 ZZ <br /> OWNER I OPE R <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME . } <br /> L <br /> SITE[ADDRESS j 16�- 1"'� LV , <br /> Street Number Direction Street Name ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY `' \ STATE C ZIP '�,\( _ <br /> PHONE#1J EXT. <br /> APN# LAND USE APPLICATION# CX-�YJ <br /> \ PHONE ill EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOI O CHECK if BILLING ADDRESS D <br /> fv' <br /> i BUSINESS NAME }� PHONE# EXT. <br /> ! 6 U 1 --(�) C)-2-1 <br /> HOME or MAILING ADDRESS FAX# <br /> b`l� - Z�( ` ( ) <br /> CITY �� STATE 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 application d thatthe wor be performed will be done in accordance ith all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard"TATE FEDERAL IawS j� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sign is require/ Ti lle <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. /� pvp� <br /> TYPE OF SERVICE REQUESTED: �0 C( �` V A yiW F: <br /> COMMENTS: rxt:cE'Veo <br /> NOV 0 2 2018 <br /> SAN JOgQUI <br /> ENVIRONMENOgNTM <br /> HEALTH p <br /> ACCEPTED BY: � J EMPLOYEE#: DATE: I <br /> ASSIGNED TO: J c, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' PIE: <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 />