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San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />City't)a <br />APN # <br />BOS District Location Code <br />Requestor <br />J <br />Ext. <br />Zip <br />led will all San Joaquin <br />ZZr2^’ <br />>GI <br />Title <br />Type of Service Requested: <br />Comments: <br />Employee#:Accepted By: <br />Date:Employee#:Assigned to: <br />Amount Paid • oo*3 <br />12^2Check #Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />07/17/08 <br />[usiness <br />DepartKi <br />aLthe above <br />itlinformation <br />1 to me or <br />Phone #2 <br />FACILITY ID # <br />FAOOO^l") <br />HOMLoUflAK-ING <br />Street Name <br />Zip <br />________ACKNOWLE^h <br />acknowledge that all site and/or orbject specific Environmental <br />activity will be billed to me or my pusiness as identified on this far <br />station and that th&-w4 <br />>TE|an£LEEDERAL laws. <br />Street Number <br />SDRESS-Of Diff< <br />P E: IV) 07 <br />T n/wvMO <br />71- T^V\|v/\aJ <br />Date Service Completed (if already completed): <br />Fee Amount: <br />Payment Type^1 <br />Service Code: <br />Payment Date <br />Received By: <br />Property / Business Owner Operator I Mai <br />If Applicant is not the BilLjng Rarvci <br />AUTHORIZATION TO RELEASE INFORMATION:^ <br />SERVICE REQUEST » <br />TOWoS <br />, — I ■■■ ■ -■ = <br />Check if Billing Address ClJU <br />Facility Name <br />Check if Billing Address LZ1 <br />zfwnc/r, operator or authorized agent of same, <br />lENT/hourly charges associate£--wlth| this project or <br />Business Nam^A <br />Home or Mailing Address /J <br />BILLING ACKNOWLEDGEMENTSCThe unde?5iqned property^cr t <br />T T ~ : ~ “x object specific Environmental>4ealth <br />y Business <br />I also certify that I have prepared rthfs apol <br />County Ordinance Codes, Stanahros^S^.i <br />APPLICANT’S SIGNATURE: \j_/_Z <br />STATO <br />Land Use Application # <br />TwgjjLBusiness or Property <br />Z/M r(L <br />Z Ope^ajor <br />fercrrt.frojrn Sitt?y\ddress) , Pc) pStreet Number <br />Phone #1 / eTt? <br />^TL^S^h <br />CONTRACTOR / SERVICE REQUESTOR <br />DflrE: <br />Phone # <br />_____J___) <br />Fax# <br />IX. ) <br />State (Q^ <br />(one in accoraance <br />Date: -p <br />HEfyAuTHORizep Agent <gy <br />prydf of authorization to sign is\equired <br />_________________________________ /Then applicable, I, tme owner oiyiperator of the pr< <br />site address, hereby authorize the release otahy and all results, geotechnical dgla^nd/or environmental&tshS^Srr^ltlinf. <br />to the San Joaquin County Environmental Health Department as soon as it is available and at the samRtoOSlVE^lT1 <br />my representative. <br />~ TEB 2 7 2019 <br />SAN JOAQUIN COUNTY <br />HFA?TuR0NMENTAt <br />health department <br />to ee p<