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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/OPERATOR �A <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Kit <br /> SITE ADDRESS I-V:K� PO,C { ' C,, te, Gl <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different fromSiteAddress) �11.�� 1 AP, <br /> wo—1 l� Street Number Street Name <br /> CITY STAT ZIP G,SZo <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> o <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) 6-C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME c PHONE# EXT. <br /> J <br /> H ME 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE: <br /> PROPERTY/BUSINESS OWNER1 , OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tir1e <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 Q d to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: r-0c-, 1CL in cl0 <br /> COMMENTS: I% - 10 <br /> - <br /> ACCEPTED BY: Z EMPLOYEE#: DATE: 1-226 I <br /> ASSIGNED TO: 7EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J Z PIE: , <br /> Fee Amount: J Amount Paid E5 c:FD I Payment Date g 2- l� <br /> Payment Typelsu Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />