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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTI*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP RATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS T-9' 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 ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (-;w Oe" mpg74 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 121&4- CHECK if BILLING ADDRESS YW <br /> BUSINESS NAME 'f / PHON # ExT' <br /> HOME or MAILIDDRF� FAx# <br /> CITY STATE ZIP 9576-, _ <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this aRplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,SNATE and FEDERAL laws. c <br /> APPLICANT'S SIGNATURE:IN11DAT.Ep:� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT'S <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 5 P <br /> COMMENTS: i)6(l `' R A,0 D6,01e A� R 16S 4PA) v ED <br /> title- Pr s pewse APR 0 2 2018 <br /> 1IN�AQUIN COON <br /> 7Y <br /> HFA, NMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: -� �- w rZ 77 V150 <br /> ASSIGNED TO: i "� L EMPLOYEE#: DATE: '-i /Z+ 47 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 2-5C F <br /> Fee Amount: -D(c, Amount Paid �(P — Payment Date <br /> Payment Type Invoice# Check# Gq') d Received By: (,46 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />