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SAN JOAPIN COUNTY ENVIRONMENTAL HEALTF-I DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# -7 <br /> ✓� 1-2.r �� C -�G SS`s rte,, / <br /> OWNER/OPERATOR n ' CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> L <br /> Street Number Direction 6 J e c /T Street Navme i ��� Zip 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 /> 9y 1-16 0 - 3- 2() G `1`�� �v � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,�n <br /> "1'C CHECK If BILLING ADDRES <br /> BUSINESS NAME <br /> lJ PHONE# EXT. <br /> I <br /> (.j C- 0 0 '7 <br /> HOME or MAILING ADDRESS FAX# <br /> S -7skva -"0-'->y/ 2z�c <br /> CITY l t / v 1 STATE C,4,_ ZIP Ca VK/ <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 I tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar ,,STATE nd FEDERAL laws <br /> APPLICANT'S SIGNATU /5�—� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LJ <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 /> 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. <br /> TYPE OF SERVICE REQUESTED: S .� � - INIgn <br /> PA <br /> COMMENTS: <br /> Ogg 15 2018 <br /> JOAQUI14 COT L <br /> N' <br /> ewoN'TMENT <br /> TN <br /> ACCEPTED BY: C' �i EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (� PI E: <br /> Fee Amount: Amount Paid (� 5 Payment Date3 zf S <br /> Payment Type Invoice# Check# 3 U Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />