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SAN JOA Q COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NER/OPERATO <br /> n I CHECK If BILLING ADDRESS El <br /> FACILITY N�"A)MIEI t�r ' 1'C ro <br /> Cro el/ '^ ('C'/ <br /> SITE ADDRESS 7S C -���Y�+t l/c /`)7 ,l <br /> Street Number Direction -� Street Name Ci ( Z &yd/o <br /> HOME or M I ADDRESS If Different from Site Address) <br /> OZStreet Number Street Name <br /> CITY / -,nSTATE �� ZIP <br /> PHONE#11(J/ EXT. APN# G. LAND USE APPLICATION# <br /> Exr. BOS DISTRICT LOCATION CODE <br /> ,2NE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 / <br /> �o ^^ _1 O ��--/. —6 t e-z CHECK if BILLING ADDRESS <br /> BUSINESS NAME Y ^r ma- u ((�"lVV/C lr'`C C> PHONE EXT. <br /> HOME orMAILING A DRESlSFAX# <br /> CITY I STATE C/9 ZIP /l <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TATE FEDERAL laws. <br /> 7 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER�f OPERATOR/MANAGER ❑ 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Sam atl' iieist�t'�viled t0 me or <br /> my representative. 1''//'''��II 1�1G��1 <br /> TYPE OF SERVICE REQUESTED: �AVb Co vS%3 `Ccs \v <br /> COMMENTS: MAR 0 2 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �\ \ EMPLOYEE#: -2) DATE: /z <br /> ASSIGNED TO: `` EMPLOYEE#: 002-1 DATE: r <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE: lU <br /> Fee Amount: f Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />