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SAN JOAQUWCOUNTY ENVIRONMENTAL HEALTH Erw{ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> F-'Aex�c>;�-v .��ZOo7Z�o8 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number DirectionStreel Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Nember Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN It LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT11 <br /> LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE // Ems' <br /> 10 S _ 22' ZI <br /> HOME Or MAILING ADDRESS FAX If <br /> CITY � STATE CA- ZIP <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 thiVap Iicationand that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNry Ordinance Codes, Standa SE and F ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> Its- <br /> PROPERTY I BUSINESS OWNER❑ P TOR I MANAGER ❑ OTHERAUTHORIZED AGENT ❑ <br /> If APPLICANT IS❑Of ILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS 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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: G, <br /> R 1V60 <br /> COMMENTS: �� �. �- <br /> AUG 1. 8 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL. <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: y #S <br /> ASSIGNED TO: ir EMPLOYEE#: DATE: / �'- <br /> Date Service Completed (if already completed): SERVICE CODE: O/�� Pit: �2go <br /> Fee Amount: Amount Paid Payment Date < % C <br /> Payment Type S Invoice# Check# Received By:I,, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />