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SAN JOAQUIN WN Ty ENVIRONMENTAL HEALTHWARTMENT <br /> SERVICE REQUEST <br /> Type siness or P o e y FACILITY ID# SERVICE REQUEST# <br /> �t�on�s S�bJr�o��3 <br /> OWN OPERA O CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESAA$$ll <br /> �V Street Number I c4ion ' 3[feC e `7� / <br /> HOME Or MAILING ADDRESS (If Di rent from Site Address) <br /> Street Number Street Name <br /> CITY /�n �„_ Q STATE ZIP <br /> PHONE#1 E'R' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST R/ , CHECK If BILLING ADDRESS <br /> BUSINESSNAME ` Pm ( 7" <br /> HOME Or MAILING A RESFAx# <br /> '-Z5-35- <br /> CIN STATE zip J <br /> l <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 projector <br /> activity will be billed tome or my busines a identified on this form <br /> I also certify that I have prepared this plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STA E and FEDERAL law t <br /> APPLICANT'S SIGNATURE: , DA''ttTE}-''II # 17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGEI�LJ � <br /> If APPLicANT is not the BILLING PA2zr proof of authorization to sign is req!!!!lICCCCCC[[[[[[//////red______ Tute <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: U-SPAYMENT <br /> COMMENTS: <br /> DEC 18 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: <br /> Fee Amount: Amount Paid 13s p Payme t Date jvo d <br /> Payment Type ✓ Invoice# Check# 13 Sri Received By: i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />