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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATPR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS J — <br /> � 310 <br /> Street Number Direction Street Name city 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 /> (7o—) 3�;L/- (y / / <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ! ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ?ra STATE ZIP �'� 3 U <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 FEDERAL IaWS. <br /> APPLICANT'S SIGNATURE: ���1 DATE: <br /> PROPERTY/BUSINESS OWNER 29 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: e <br /> l n; ms- RIGC0...-EI IED <br /> COMMENTS: N O V 12 L W <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /�\ ) �/1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ` PIE: G <br /> Fee Amount: Amount Paid Z ci �? ? Payment Date '— <br /> Payment Type Invoice# Check# l 7 Iieceived By: <br /> n C //�(, T �lCz S c a�'I�t. U�t�Lvl C c 'ZQ�D,d <br /> EHD 48-02-025 1J SR FORM(Golden Rod) <br /> 07/17/08 <br />