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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Ur-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR C / <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS t �1I C ` V` /�J J ' <br /> Street Number Direction Street Name cI i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) rrhL� r �r <br /> Street-N,mber Street Name <br /> CITY STATE ZIP <br /> PHONE#1 v, I EXT. APN# LAND USE APPLICATION# <br /> 444) <br /> PHONE#2 EXT. BOS DISTRICT_ LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �om' e �err�(�T yam{ <br /> � C-.-� 1 'lJ CHECK If BILLING ADDRE6rr`1 <br /> BUSINESS NAME �I I OI I �{-7 } f C//��r�4���r PHONE# /`fir,,1 JI(I J 1_, q( OXT• <br /> HOME or MAILING ADDRESS I1j-j`/1 :A a 1. Ifr— )1116 Dr . FAX# 1(J JIJJ l 1�fCJ <br /> CITY (�( C. It I STATE Cts ZIP l {�2 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDE AL wS. <br /> APPLICANT'S SIGNATURE: ` DATE: h`f t 17 <br /> PROPERTY I BUSINESS OWNE� OPERATOR t MAN ER d OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirte <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/ ' S�es7sment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Sam t upp to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> t ' by <br /> COMMENTS: 06 0 3 2011 <br /> SAN JOAQUIN C <br /> MEN7. <br /> ACCEPTED BY: =` EMPLOYEE#: DATE: j <br /> ASSIGNED TO: { t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: , r .` Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />