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SAN JOAQum COUNTY ENVIRONMENTAL HEALTH L+cPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> •o <br /> SITE ADDRESS1 t1 /•vA` qS--3i1 <br /> Street Number Direction °v `� \'L1� Str eAName C a 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 <br /> EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ' , / J � CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' 4g_ PHO # ��/(_ EXT. <br /> V (.� Z <br /> HOME or MAILING ADDRESS 1 FAX# <br /> CITY // STATE ZIP o <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,S ATE nd F DERAL I s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER Q 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 Same time It IS provided t0 me or <br /> my representative. <br /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: GS� Fi nrj <br /> RECEIVED <br /> COMMENTS: <br /> JUL 0 3 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: d DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (0! P I E: <br /> Fee Amount: OV Amount Paid J cy Payment Date "3 7 <br /> Payment Type Ca S Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />