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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 111 <br /> SERVICE REQUEST �� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME�j <br /> r� <br /> SITE AC-7DDRESS 1/1 �, /1 �.� D46 <br /> 5 6 Street Number I Direction ►/\ Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address)�77r1 <br /> t f Street Number Street Name <br /> CITY t STATE ZIP <br /> PHONE##11 (J EXT. APN# Q LAND USE APPLICATION# <br /> PHONE ill EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �0. �_ CHECK if BILLING ADDRESS <br /> BUSINE S AME ^ Q ` V�j�1 PHO E# V� ^ EXT' <br /> HOME or MAILING ADDRES� FAX# <br /> CITY (1_ t I STATE e—f _ ZIP �S� tk-- <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 lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ 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 /> TYPE OF SERVICE REQUESTED: 6 <br /> COMMENTS: /—� '/�/ L%%�a�C �i� M / � � <br /> 6�) Sirl c- �er'*4-7. eta 6?e60 9-C-3 7 -r-O Se,~ <br /> L" tel . &f/ <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Gl ' P I E: <br /> Fee Amount: � Amount Paid Payment Date 31/12 <br /> Payment Type � Invoice# Ch k# �9 ecei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />