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SAN JOAQUIN ('OLTNTY ENVIRONNIENTAL HEAL'I'r'')EPARTMENT <br />SERVICE REQUEST <br />T e pf Busines or rop y , <br />yJ <br />FACILITY ID # <br />EN <br />I'AYM <br />SERVICE REQUEST # <br />S200 5 3 7 3 <br />0W4R / OP <br />RA OR <br />n � <br />f •C <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />PHO EXT. <br />4 /-4355 r <br />(ffjj 1 (�(.,J� <br />HOME or MAILINGADDRESS <br />SITEADDR,ES,S <br />�/ <br />� �'�" <br />Street Number <br />� rtion <br />Dirt <br />q�a/r6ti!��tNalee/ <br />SAN <br />Zi Code <br />HOME or MAILIN <br />ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#Z <br />( ) <br />EXT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />EN <br />I'AYM <br />CHECK If BILLING ADDRE <br />l/ <br />l <br />BUSINESS NAME <br />/ <br />PHO EXT. <br />4 /-4355 r <br />(ffjj 1 (�(.,J� <br />HOME or MAILINGADDRESS <br />FAX #q <br />SAN <br />CITY <br />STATE <br />BILLING ACKNONVL kDAMENT: 1, 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 ap i tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Cortes, Standards, S A , and FEDERA{, laws. <br />APPLICANT'S SIGNATURE: DATE: (J U N <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is require Tirl e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />EN <br />I'AYM <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JAN 2 2 2008 <br />SAN <br />NVVIRONIMENOTALTM <br />HEALTH nEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M Z <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: 2 <br />Fee Amount: °' <br />Amount Paid <br />;1-,7• o -Z:) <br />Payment Date ( Zy <br />Payment Type <br />Invoice # <br />Check # (� �_ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />