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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typ�Business Property FACILITY ID# SERVICE REQUEST# <br /> - AW ✓12 OD736g(3' <br /> OJtJR I PE7 <br /> ;0 <br /> CHECK if BILLING ADDRESS D <br /> FACIUI Y NAM�j <br /> TD ES$ /`S�'Lrl'RU Direction `�(/' ' eet ICbQeO <br /> HOvf MAI ADDRESS (I Diff from Site Address) <br /> Street Number7 Street Name <br /> CITY- 4-61� STATE zip a <br /> pH� #1��� � •�� APN t/ _ O / LAND USE APPLICATION# <br /> ) <br /> BOS DISTRICT ][LOCATION CODE <br /> CONTRACT R/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NA E ei P it EXT. <br /> HOME or MFAX# <br /> ( ) REc� <br /> WT <br /> AIL G D ED <br /> CITY TATE zip r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorize DEC4®�1 ame, <br /> ry <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associate��,7r <br /> ��fc6T(/N <br /> activity will be billed tome or my business as id tified on this form. LTH DFP N A( <br /> T <br /> I also certify that I have prepared this appli ti d t the work to be performed will be done in accordance with all SAN JOAQrMENT <br /> COUNTY Ordinance Codes, Standards, ST �d u aws. <br /> APPLICANT'S SIGNATURE: DATE: , <br /> PROPERTY/BUSINESS OWNER 11OPERATOR/MA GER ❑ OTHER AUTHORIZED AGENT AI <br /> If APPLICANT is not the BILLING PART_',proof of authorization to sign is required Tit[ <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/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: <br /> .:OMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: n/�Q�{ S - EMPLOYEE#: DATE: `l 1 <br /> Date Service Completed (if already completed): SFRVICE CODE: PIE: <br /> Fee Amount: 3G�(U 'v Amount Pai Payment Date '�_ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />