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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CIVVNEr;/ PERA.TOR CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> L" t <br /> SITE ADDRESS <br /> Street Number Direction __ Street Name I rbi _ zip Ccd <br /> HUME Or MAILING ADIIRE S (If Different q`\ro�rrySite ddress) <br /> Street Number '- Street Name <br /> CITY _ STATE ZIP <br /> \ � <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> (tet) ILL ------ <br /> CONTRACTOR / SERN710E REQUESTOR <br /> REQ STOR � <br /> (-_V\Y �� V�\� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> I2 k <br /> HOME or MAILING AD9RESSr FAX# <br /> 1Y ( ) <br /> CITY I (1,� STATE C 1 ZIP Z <br /> BILLING ACKNOWLEDGEMiENT: i, the undersigned property or business owner, opYerrator 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, STAT and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: %� I`G b c e---z. I DATE: 2-116 <br /> _ <br /> PROPERTY/BUSINESS OWNER OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: I c�— smox <br /> COMMENTS: - <br /> `rSEP 1 <br /> h is i-e- L `����C., SA 4 JOAQUIN CC UNTY <br /> ENVIR0M'Ef1j L <br /> HEALTH DEPAP►T M04T <br /> ACCEPTED BY: /7 EMPLOYEE#: DA FE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: / <br /> Date Service Completed • already completed): SERVICE CODE: 5D—i P.'E: <br /> Fee Amount; Amount Paid ,i -� -" ! Payment Date <br /> Payment Type �. Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/1-008 <br />