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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NER/OPERATQR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSZ// `�� V� t� <br /> , <br /> Street Number Direction K- Street Name C•-itv Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> RudStreet Number I � <br /> -/ Street Name <br /> CI <br /> PHONE#1 � Ext. u TATE Z� <br /> _` APN rr LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) ("r fl�. <br /> CONTRACTOR/ SERVICE REQUEST®R <br /> REQUESTOR ��<�' <br /> `-t+ HECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX.# <br /> CITY STATE 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 this application and t at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST an DE L laws. <br /> APPLICANT'S SIGNATURE: DATE:— <br /> MANAGER <br /> ATE:- <br /> PROPERTY/BUSINESS OWNER❑ OPERA R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 pr�JjN;C� to me or <br /> my representative. IGS j/ <br /> TYPE OF SERVICE REQUESTED: FC�2s71 je/� <br /> COMMENTS: <br /> sqN� 13 2015 <br /> EIy(DgOUIN <br /> NFqtTH OF ARTM1 N <br /> FNT <br /> ACCEPTED BY EMPLOYEE#: DATE: I C <br /> ASSIGNED TO: n EMPLOYEE#: DATE: I J <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: O <br /> Fee Amount: Amount Pa i G t� (]� Payment Date S <br /> Payment Type Invoice# Check# I�L Received By: <br /> EHD 48-02-025 SR FORMI(Golden Rod) <br /> 07/17/08 <br />