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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S '� o� a"a <br /> 12 T 1-7c) S-- S1200 �J3— S <br /> OWNER/OPERATOR },,, CHECK If BILLING ADDRESS❑ <br /> I l c �( <br /> FACUTY NAME <br /> SITE ADDRESS <br /> I4Street Number I Direction I-1 Street Name Ci Zip 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 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> PE `CLQ l- 6 ExT. <br /> C�l <br /> BUSINESS NAME <br /> � QN s Cti• <br /> HOME Or MAILING ADDRESS FAX# <br /> as3s I �m qw- � <br /> CITY $TATE P <br /> Gl _ <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 a lication and that the work to be performed will be done in accor ce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa ds, TATE and FEDERAL laws. ' <br /> APPLICANT'S SIGNATURE /Wl / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL/CANT 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 <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 /> TYPE OF SERVICE REQUESTED: L(nSr —r-p— 1IGt T PAYMENT- <br /> COMMENTS: <br /> JAN 2 0 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: U`r v E t lQ EMPLOYEE#: 032 DATE: ` 2,o Q <br /> ASSIGNED TO: L... EMPLOYEE#: 3S� DATE: ft <br /> Date Service Completed (if already Completed): SERVICE CODE: [ 70 8 <br /> Fee Amount: ?9,w Amount Paid Payment Date p <br /> Payment Type `� Invoice# Check# Received y: N C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />