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• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of usiness or Property FACILITY ID# ERVICE REQUEST# <br /> OWER/ RATOR <br /> `�'1 / ,� CHECK If BILLING ADDRESS <br /> 71',FACILITY NAME 1 Iv <br /> SITE ADDRESS <br /> `Street Number I Direction 1., Street Rame l �Ci � Zi Code <br /> HOME"AILING ADDRESS (I Di ernt f�Site Address) <br /> If/ 3 Street Number Street Name <br /> CITY STATE n ZIP G /, <br /> PHONE#1 i EXT- APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �,I -v CHECK if BILLING ADDRESS <br /> BUSINESS NAME J/ q PHONE# ExT. <br /> HOME or MAILING ADDRESS ' / FAX# <br /> Lo <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 /> 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: 9/ ^ - <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I(APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirle <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 s �ti e it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: food Lh('W <br /> COMMENTS: 'NO % 6 2018 <br /> SAN JOAQUIN <br /> ENVIRON COUNTY <br /> HEALTH pE ARl-MENT <br /> ACCEPTED BY: C 1 L EMPLOYEE#: ) DATE: / <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already comple ed): SERVICE CODE: PIE: <br /> Fee Amount• N 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 />