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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> aoo <br /> OWNER / OPERATOR <br /> � CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> r J <br /> SITE ADDRESS CO t ( jL1 _ 1 ip o/de [ <br /> Street Number Direction LStree ame tom/ ( �i •O!o �T <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 /> ( Caj'f 144 y <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUST pssNAMEPHONE # EXT. <br /> 4 -oil/ ��t/1�i >L/r/ %�L C��t/.fi , <br /> Ho E or MAILI ADDRESS <br /> FAX <br /> 70 4 .3,61 c a 33 ( ) �J <br /> TATE ZIP Qj73 <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 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 : 3 �'103 /� y� �J <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT C ljj° %� 4 /t- / C/ /4 <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 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. <br /> TYPE OF SERVICE REQUESTED : { 7 2L �� < C PAYMENT. <br /> COMMENTS : RECEIVED <br /> MAY 0 3 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> pq <br /> ACCEPTED BY: EMPLOYEE #: ;� �, DATE : r� <br /> ASSIGNED TO : ) EMPLOYEE #: �' DATE : 3 I <br /> U i I \ G. f �� <br /> Date Service Completed (if already completed) : SERVICE CODE: r (� PIE : Z 30 <br /> Fee Amount : � ��- �2 Amount Paid 4 � / �(p Payment Date I I <br /> Payment Type t Invoice # Check # D 7 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />