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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bus' ss or Property FACILITY ID# SERVICE RE EST# <br /> OWNEO OPERATOR U <br /> UQ 1 (Q q <br /> /J'I In LIP A- it)i V J/,^ A A b,l ` CHECK If BILLING ADDRESS <br /> FACILITY NAf1M77EC-) 1 G'l G IAn GT-),l 'IF <br /> T A DRES/7q'���/ A�,,c, � Jly �71_ Cl 5 2v�n <br /> � �""SEr€et Number Direction •��`� Street NameC- City Zin Code <br /> HOMEOr ILING ADDRES5,,(If Different from Site/�i�ress) <br /> r/ Street Number Street Name <br /> CITY e �,J ST T� ZIP $16 <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAh laws. <br /> APPLICANT'S SIGNATURE: C� Icc�7�� � •�. DATE: <br /> PROPERTY/BUSINESS OWNER 19 OPERATOR/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, 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 provideome or <br /> my representative. Y <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: C I <br /> O1G.r <br /> MDC) 21�1 +L1 JIJ ys ogQ��3?0 <br /> 4N <br /> MF�'T <br /> ACCEPTED BY: �V1'4n EMPLOYEE#: DATE: <br /> ASSIGNED TO: n EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (v PIE: <br /> Fee Amount S2 D-D Amount Pai Payment Date l <br /> Payment Type Invoice# Check# 3g`7 Redeive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />