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SAN JOAQUOI. COUNTY ENVIRONMENTAL HEALTH IPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _ SERVICE REQUEST# <br /> `-7 <br /> OWNER/OPERATOR n J CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> \y4r� <br /> Street Number Direction ��" Street NYame l/C i �i d� 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 /> PHONE#2 EXT. BOS DDID" <br /> CONTRACTOR <br /> LOCATIO� ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �. <br /> 5�) ( A i \ 4�J(J(j t..L S CHECK if BILLING ADDRES <br /> BUSINESS NAME (� PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY (l LL U n 1 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_appl-iEWion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards'STATE Ind FEDERAL laws <br /> I �y <br /> APPLICANT'S SIGNATU <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LI �j (/ ��,r (jrt��c' ,r <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. e <br /> TYPE OF SERVICE REQUESTED: S`r � �- L, PA <br /> COMMENTS: <br /> COU%MAO � � 2018 <br /> J�i�LAMENT LTy, <br /> ENS OiPA¢SMENT <br /> ACCEPTED BY: C_._'nL� "j� EMPLOYEE#: DATE: <br /> SJl V J r <br /> ASSIGNED TO: _ FlEMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: / PIE: �� ✓✓✓ <br /> Fee Amount: Amount Paid ' ' rJ Payment Date '7-11 <br /> Payment Type '�-L< Invoice# Check# Received By: 7"' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />