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L <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> _ kl)IZ ` <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <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 /> ( ) () ) "!)).2 )05 `( <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Gp` CHECK If BILLING ADDRESS <br /> 4j <br /> BUSINESS NAME PHONE# EXT. <br /> ��.-��s �y C/ 31- <br /> HOME or MAILING ADDRESS FAX# <br /> 3 ( ) <br /> CITY /L G� L �S _� 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 I BUSINESS OWNER 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided to rile Or <br /> my representative. •.: <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SqN�O <br /> FNtr 1 <br /> N��TN�Fp,�R <br /> 17-4N�' <br /> �VIZVII( IENT <br /> ACCEPTED BY: SS's `/yr1 EMPLOYEE#: DATE: - J ' I '7 <br /> ASSIGNED TO: h, Y,\ EMPLOYEE#: DATE: .2 - S - i y <br /> Date Service Completed (if already completed): SERVICE CODE: V W ' PIE: yz v <br /> Fee Amount: , S �2— Amount Pai /SZ 60 Payment Date77 <br /> / <br /> Payment Type �y Invoice# Check# Rec ved By: <br /> EHD 48-02-025 / J 1 SR FORM(Golden Rod) <br /> 07/17/08 b�aG� �d G.5.��� C�L- / CSr=- <br />